1649257767 NPI number — MR. ANTONIO CORDOVA III MS, ATC

Table of content: MR. ANTONIO CORDOVA III MS, ATC (NPI 1649257767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649257767 NPI number — MR. ANTONIO CORDOVA III MS, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORDOVA
Provider First Name:
ANTONIO
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
MS, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649257767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3660 MORNING MEADOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-7602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-386-0480
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 26TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-569-4900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AL1499 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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