Provider Demographics
NPI:1689790057
Name:FLORESTAL, JEAN PATRICK (L M T)
Entity Type:Individual
Prefix:MR
First Name:JEAN PATRICK
Middle Name:
Last Name:FLORESTAL
Suffix:
Gender:M
Credentials:L M T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 MARBLE CT
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-9398
Mailing Address - Country:US
Mailing Address - Phone:407-696-6962
Mailing Address - Fax:
Practice Address - Street 1:1000 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8140
Practice Address - Country:US
Practice Address - Phone:407-971-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA27106225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA27106OtherLICENSE NUMBER