Healthcare Provider Details

I. General information

NPI: 1306134390
Provider Name (Legal Business Name): PANTALEON DELROSARIO LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 EAGLE POND DR
WINTER HAVEN FL
33884-1296
US

IV. Provider business mailing address

1201 EAGLE POND DR
WINTER HAVEN FL
33884-1296
US

V. Phone/Fax

Practice location:
  • Phone: 863-521-1909
  • Fax:
Mailing address:
  • Phone: 863-521-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA20660
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: