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General NPI Number Information
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NPI Number | 1649257767
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Entity Type | Individual
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Provider Name | ANTONIO CORDOVA III MS, ATC
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Gender | Male
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Dates
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Enumeration Date | 12/29/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4001 26TH ST
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City | VERO BEACH
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State | FL
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Zip | 32960-1930
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Country | US
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Telephone | 772-569-4900
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Fax |
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Provider Business Mailing Address
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Address Line | 3660 MORNING MEADOW LN
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City | ORANGE PARK
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State | FL
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Zip | 32073-7602
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Country | US
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Telephone | 904-386-0480
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL1499
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License Number State | FL
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