Healthcare Provider Details

I. General information

NPI: 1790361566
Provider Name (Legal Business Name): TYLER DONALD KLAWINSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 AVENUE O NE
WINTER HAVEN FL
33881-2409
US

IV. Provider business mailing address

1652 CELEBRATION BLVD UNIT 311
CELEBRATION FL
34747-5525
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-3103
  • Fax:
Mailing address:
  • Phone: 850-694-8802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA16263
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: