MEDICARE: RICHARD ANTEAU II

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	225200000X	Physical Therapy Assistant	PTA27990	FL

General Provider Information

NPI Number	:	1083187793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD ANTEAU II

Provider Business Mailing Address
First Line	:	2623 COUNTRY SIDE DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4953
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2623 COUNTRY SIDE DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4953
Country	:	US
Telephone Number	:	320-460-0929
Fax Number	:

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

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	06/28/2019

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Directions to “ RICHARD ANTEAU II ” Practice Location

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