Healthcare Provider Details

I. General information

NPI: 1144062183
Provider Name (Legal Business Name): MARCUES RESHAY SALLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 AVENUE C SE
WINTER HAVEN FL
33880-3243
US

IV. Provider business mailing address

715 STRAIN BLVD
LAKELAND FL
33815-1149
US

V. Phone/Fax

Practice location:
  • Phone: 863-268-2903
  • Fax:
Mailing address:
  • Phone: 352-461-9597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPT32708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: