Provider Demographics
NPI:1225312804
Name:GUMBA, ROLANDO JET BACALZO II
Entity Type:Individual
Prefix:MR
First Name:ROLANDO JET
Middle Name:BACALZO
Last Name:GUMBA
Suffix:II
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 1:1580 SAWGRASS CORPORATE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2860
Mailing Address - Country:US
Mailing Address - Phone:352-346-8420
Mailing Address - Fax:
Practice Address - Street 1:1580 SAWGRASS CORPORATE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2860
Practice Address - Country:US
Practice Address - Phone:352-346-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist