Healthcare Provider Details

I. General information

NPI: 1811425713
Provider Name (Legal Business Name): LEO HURTADO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 05/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 6TH ST NW
WINTER HAVEN FL
33881-2368
US

IV. Provider business mailing address

3081 GRAND PRESERVE BLVD
MULBERRY FL
33860-0079
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-3055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA24219
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: