Provider Demographics
NPI:1700352838
Name:SANSOUCI III, ROBERT J III
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:SANSOUCI III
Suffix:III
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 1:560 SW MCFARLANE AVE, LAKE CITY, FL, 32025
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 SW MCFARLANE AVE, LAKE CITY, FL, 32025
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-758-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28885225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant