Basic Information
| Provider Information | |||||||||
| NPI: | 1720485113 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GOVEA | ||||||||
| FirstName: | ROGELIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 ROSELAWN ST SW | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338802743 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3350 W SOUTHPORT RD | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347462706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078460152 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2014 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 25156 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.