Provider Demographics
NPI:1487007209
Name:BEWERSDORF, ALLAN JR (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:BEWERSDORF
Suffix:JR
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 16TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3626
Mailing Address - Country:US
Mailing Address - Phone:772-564-5494
Mailing Address - Fax:
Practice Address - Street 1:1707 16TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3626
Practice Address - Country:US
Practice Address - Phone:772-564-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-16
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL15252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer