Provider Demographics
NPI:1205008364
Name:LAVARIAS, IMELDA C
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:C
Last Name:LAVARIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 HERBERT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4135
Mailing Address - Country:US
Mailing Address - Phone:386-763-9800
Mailing Address - Fax:386-763-0828
Practice Address - Street 1:1321 HERBERT ST
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4135
Practice Address - Country:US
Practice Address - Phone:386-763-9800
Practice Address - Fax:386-763-0828
Is Sole Proprietor?:No
Enumeration Date:2008-03-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist