Provider Demographics
NPI:1518578038
Name:SRIVIBUL, SIDNEY
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:
Last Name:SRIVIBUL
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 1:2961 NE 185TH ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-5338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 S LAWRENCE BLVD
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9222
Practice Address - Country:US
Practice Address - Phone:352-473-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist