Provider Demographics
NPI:1881001394
Name:MERCADO, REGIE
Entity Type:Individual
Prefix:
First Name:REGIE
Middle Name:
Last Name:MERCADO
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 1:315 NE 3RD AVE
Mailing Address - Street 2:APT 1507
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1631
Mailing Address - Country:US
Mailing Address - Phone:310-849-9961
Mailing Address - Fax:
Practice Address - Street 1:1615 MIAMI RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2933
Practice Address - Country:US
Practice Address - Phone:310-849-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 28009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist