Provider Demographics
NPI:1295365526
Name:FLEITAS, JUAN CARLOS (MA 67136)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:FLEITAS
Suffix:
Gender:M
Credentials:MA 67136
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:FLEITAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA 67136
Mailing Address - Street 1:1660 55TH AVENUE CIR E APT 203
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-4483
Mailing Address - Country:US
Mailing Address - Phone:941-592-4393
Mailing Address - Fax:
Practice Address - Street 1:1900 MAIN ST STE 108
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-5950
Practice Address - Country:US
Practice Address - Phone:941-592-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
FLMA67136225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA67136Medicaid