Provider Demographics
NPI:1164166526
Name:POBLETE, MARCO (PT)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:POBLETE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8939
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33806-8939
Mailing Address - Country:US
Mailing Address - Phone:863-617-9400
Mailing Address - Fax:863-688-9858
Practice Address - Street 1:1485 SHOREWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4229
Practice Address - Country:US
Practice Address - Phone:863-617-9400
Practice Address - Fax:863-688-9858
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist