Healthcare Provider Details

I. General information

NPI: 1669070884
Provider Name (Legal Business Name): JENIVIEVE JANET PREZAS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 NORFOLK PKWY STE 116
WEST MELBOURNE FL
32904-8617
US

IV. Provider business mailing address

709 S HARBOR CITY BLVD STE 100
MELBOURNE FL
32901-1936
US

V. Phone/Fax

Practice location:
  • Phone: 321-802-5816
  • Fax: 321-802-5811
Mailing address:
  • Phone: 321-722-7225
  • Fax: 321-308-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT30372
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: