Provider Demographics
NPI:1114682929
Name:ACOSTA, ANGEL EDUARDO
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:EDUARDO
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-9740
Mailing Address - Country:US
Mailing Address - Phone:321-203-9022
Mailing Address - Fax:
Practice Address - Street 1:988 CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-9740
Practice Address - Country:US
Practice Address - Phone:321-203-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91711225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty