Provider Demographics
NPI:1588010904
Name:VERGARA, DARYL LAWRENCE (PTA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:LAWRENCE
Last Name:VERGARA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RAE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6880
Mailing Address - Country:US
Mailing Address - Phone:386-237-8588
Mailing Address - Fax:
Practice Address - Street 1:84 PINNACLES DR
Practice Address - Street 2:#300
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2324
Practice Address - Country:US
Practice Address - Phone:386-447-7824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22353225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant