=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679535801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT GORDON COUTU MS, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 SE 17TH ST SUITE 302
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-9144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-629-4509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 N EVERLASTING DR
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34465-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | AL 1833
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------