Basic Information
| Provider Information | |||||||||
| NPI: | 1295338788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVENA | ||||||||
| FirstName: | CARLO | ||||||||
| MiddleName: | GABRIEL | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 BROAD ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078330802 | ||||||||
| FaxNumber: | 4078338931 | ||||||||
| Practice Location | |||||||||
| Address1: | 1337 S INTERNATIONAL PKWY STE 1321 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327461402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078330802 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2020 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT36599 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.