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NPI Code Detail

MEDICARE: MARDONE RIVERA TAN PT

MEDICARE: MARDONE RIVERA TAN PT
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
1225100000XPhysical TherapistPT 22587FL

General Provider Information

NPI Number : 1740306190
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARDONE RIVERA TAN PT
Provider Business Mailing Address
First Line : 503 CROWNE SUNSET DR
Second Line : APT. 1323
City : ORMOND BEACH
State : FL
Zip : 32174-0666
Country : US
Telephone Number : 407-929-9165
Fax Number :
Provider Business Practice Location Address
First Line : 350 S RIDGEWOOD AVE
Second Line :
City : ORMOND BEACH
State : FL
Zip : 32174-7028
Country : US
Telephone Number : 386-677-4545
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/21/2007
Last Update Date : 07/08/2007

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Directions to “ MARDONE RIVERA TAN PT” Practice Location

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