Provider Demographics
NPI:1649864257
Name:BURGOS, JUSTIN M (PTA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:BURGOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 N ORANGEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-7891
Mailing Address - Country:US
Mailing Address - Phone:956-463-0027
Mailing Address - Fax:
Practice Address - Street 1:1601 6TH ST SE STE B
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4605
Practice Address - Country:US
Practice Address - Phone:863-294-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30326225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty