=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538817549
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALE RAYMOND MARHEFKA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2022
-----------------------------------------------------
Last Update Date | 03/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1840 N DIXIE HWY
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-1845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-961-4726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 CREST DR
-----------------------------------------------------
City | WESTFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01886-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-244-8088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT35443
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------