Provider Demographics
NPI:1811538721
Name:SOUFFRONT, RAYNALDO (PT)
Entity Type:Individual
Prefix:
First Name:RAYNALDO
Middle Name:
Last Name:SOUFFRONT
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 1:453 SAND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4058
Mailing Address - Country:US
Mailing Address - Phone:813-699-4026
Mailing Address - Fax:
Practice Address - Street 1:11930 BOYETTE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5601
Practice Address - Country:US
Practice Address - Phone:813-671-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist