Basic Information
| Provider Information | |||||||||
| NPI: | 1033743646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANESTRARI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8477 S SUNCOAST BLVD | ||||||||
| Address2: | |||||||||
| City: | HOMOSASSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523827214 | ||||||||
| FaxNumber: | 3524487857 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 S COURTENAY PKWY | ||||||||
| Address2: | |||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329523804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214521233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA20279 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.