Provider Demographics
NPI:1710075163
Name:BOSCO, DANIEL JACOB (PT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:BOSCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 EAGLE ROCK AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3167
Mailing Address - Country:US
Mailing Address - Phone:239-574-8922
Mailing Address - Fax:239-573-7356
Practice Address - Street 1:13670 METROPOLIS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4346
Practice Address - Country:US
Practice Address - Phone:239-561-0700
Practice Address - Fax:239-561-5643
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist