Healthcare Provider Details

I. General information

NPI: 1902920523
Provider Name (Legal Business Name): KEVIN PATRICK ANDERSON M.P.T., CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 S ORLANDO AVE
WINTER PARK FL
32789-4852
US

IV. Provider business mailing address

770 HUNTINGTON PINES DR
OCOEE FL
34761-3368
US

V. Phone/Fax

Practice location:
  • Phone: 321-277-9314
  • Fax: 407-628-2572
Mailing address:
  • Phone: 321-277-9314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT18060
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: