Basic Information
| Provider Information | |||||||||
| NPI: | 1538575881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TELLEZ | ||||||||
| FirstName: | EVERARDO 'LALO' | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 E ORANGE ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338015054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636179400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 411 E ORANGE ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338015054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636179400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA1700 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.