Provider Demographics
NPI:1760973572
Name:BELLAVISTA, SOPHIA DIANE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:DIANE
Last Name:BELLAVISTA
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:43 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7416
Mailing Address - Country:US
Mailing Address - Phone:904-669-0020
Mailing Address - Fax:
Practice Address - Street 1:100 EXECUTIVE WAY STE 109
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2713
Practice Address - Country:US
Practice Address - Phone:904-543-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer