Provider Demographics
NPI:1811571508
Name:DE REAL, REYMON LOBOS
Entity Type:Individual
Prefix:
First Name:REYMON
Middle Name:LOBOS
Last Name:DE REAL
Suffix:
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 1:2831 N OCEAN BLVD APT 408N
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7583
Mailing Address - Country:US
Mailing Address - Phone:305-812-1427
Mailing Address - Fax:
Practice Address - Street 1:2831 N OCEAN BLVD APT 408N
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7583
Practice Address - Country:US
Practice Address - Phone:305-812-1427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist