Provider Demographics
NPI:1982033932
Name:BALBOA, JUAN MARTIN ROMERO (RPT)
Entity Type:Individual
Prefix:
First Name:JUAN MARTIN
Middle Name:ROMERO
Last Name:BALBOA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:797 TEAGUE TRL
Mailing Address - Street 2:APT 2202
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3110
Mailing Address - Country:US
Mailing Address - Phone:402-957-4248
Mailing Address - Fax:
Practice Address - Street 1:797 TEAGUE TRL
Practice Address - Street 2:APT 2202
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3110
Practice Address - Country:US
Practice Address - Phone:402-957-4248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-09
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26216225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist