MEDICARE: MR. PERRY DEAN REVLETT MA.ATC,LAT

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	2255A2300X	Athletic Trainer	AL 333	FL

General Provider Information

NPI Number	:	1588609341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PERRY DEAN REVLETT MA.ATC,LAT

Provider Business Mailing Address
First Line	:	342 N THORPE AVE
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-5241
Country	:	US
Telephone Number	:	386-774-4107
Fax Number	:

Provider Business Practice Location Address
First Line	:	926 HOWLAND BLVD
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32738-7139
Country	:	US
Telephone Number	:	407-688-9500
Fax Number	:

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

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	07/21/2022

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