Provider Demographics
NPI:1750855037
Name:MAND, ROBERT (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MAND
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 1:9118 E MOCCASIN SLOUGH RD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-6203
Mailing Address - Country:US
Mailing Address - Phone:352-860-2417
Mailing Address - Fax:
Practice Address - Street 1:490 S OLD WIRE RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-5001
Practice Address - Country:US
Practice Address - Phone:352-748-3683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20147225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant