Provider Demographics
NPI:1770656779
Name:REBOLLEDO, JAVIER (PT)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:REBOLLEDO
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 1:838 SW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-7223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1116
Practice Address - Country:US
Practice Address - Phone:239-277-9818
Practice Address - Fax:239-277-9289
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT14471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0802ZMedicare ID - Type UnspecifiedMEDICARE ID