Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT21044 | FL |
NPI | 1003000381 |
---|---|
Provider Name | Mr. Luther Quitoriano Braganza |
First Address | Leesburg, FL 34788-3130 |
Second Address | Lady Lake, FL 32159-4347 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2007 |
Last Update Date | 30/08/2007 |