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General NPI Number Information
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NPI Number | 1487094983
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Entity Type | Organization
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Legal Business Name | JAESEN PETRETTA INC
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Dates
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Enumeration Date | 06/28/2013
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Last Update Date | 06/28/2013
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Provider Practice Location Address
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Address Line | 12995 S CLEVELAND AVE STE 158
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City | FORT MYERS
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State | FL
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Zip | 33907-3867
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Country | US
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Telephone | 239-839-3408
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Fax |
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Provider Business Mailing Address
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Address Line | 4281 7TH AVE SW
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City | NAPLES
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State | FL
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Zip | 34119-4029
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAESEN PETRETTA
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Credential | OTR/L
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Telephone | 239-839-3408
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | OT10199
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License Number State | FL
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