Provider Demographics
NPI:1740306190
Name:TAN, MARDONE RIVERA (PT)
Entity type:Individual
Prefix:
First Name:MARDONE
Middle Name:RIVERA
Last Name:TAN
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 1:503 CROWNE SUNSET DR
Mailing Address - Street 2:APT. 1323
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-0666
Mailing Address - Country:US
Mailing Address - Phone:407-929-9165
Mailing Address - Fax:
Practice Address - Street 1:350 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7028
Practice Address - Country:US
Practice Address - Phone:386-677-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 22587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist