MEDICARE: EARL NORBERT O. DIMAANO DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251G0304X	Geriatric Physical Therapist	PT36611	FL

General Provider Information

NPI Number	:	1063008357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL NORBERT O. DIMAANO DPT

Provider Business Mailing Address
First Line	:	7451 103RD ST STE 12
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-6788
Country	:	US
Telephone Number	:	904-771-3679
Fax Number	:

Provider Business Practice Location Address
First Line	:	7451 103RD ST STE 12
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-6788
Country	:	US
Telephone Number	:	904-771-3679
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2020
Last Update Date	:	12/21/2020

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