Provider Demographics
NPI:1750835344
Name:PHILLIPS, ALONZIA III
Entity Type:Individual
Prefix:
First Name:ALONZIA
Middle Name:
Last Name:PHILLIPS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 10TH RD SW APT 217
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-5252
Mailing Address - Country:US
Mailing Address - Phone:772-925-2489
Mailing Address - Fax:
Practice Address - Street 1:2330 10TH RD SW APT 217
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-5252
Practice Address - Country:US
Practice Address - Phone:772-925-2489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities