=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942383039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY VASTANO RPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 12/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 W NORTH BLVD, SUITE D
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-5063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-728-6636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1134 FIELDBROOK WAY
-----------------------------------------------------
City | THE VILLAGES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32163-2225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-305-4965
-----------------------------------------------------
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 | 40QA00452300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 31651
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------