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General NPI Number Information
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NPI Number | 1154608149
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Entity Type | Individual
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Provider Name | ROBERTA BORNEMANN L M T
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Gender | Female
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Dates
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Enumeration Date | 11/04/2011
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Last Update Date | 11/04/2011
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Provider Practice Location Address
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Address Line | 519 MILL RUN DRIVE
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City | NEW SMYRNA
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State | FL
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Zip | 32168
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Country | US
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Telephone | 386-428-5914
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Fax |
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Provider Business Mailing Address
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Address Line | 519 MILL RUN DR
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City | NEW SMYRNA
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State | FL
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Zip | 32168-1929
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Country | US
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Telephone | 386-428-5914
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA19781
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License Number State | FL
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