Provider Demographics
NPI:1700993532
Name:BERNARDO, RICKY (PT)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:BERNARDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 BROKEN SOUND PKWY NW
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-3507
Mailing Address - Country:US
Mailing Address - Phone:561-241-9300
Mailing Address - Fax:561-372-0214
Practice Address - Street 1:3501 CORTEZ RD W
Practice Address - Street 2:POD #2
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3104
Practice Address - Country:US
Practice Address - Phone:941-757-6300
Practice Address - Fax:941-757-8877
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20720174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT20720OtherSTATE LICENSE