Provider Demographics
NPI:1740648310
Name:GERVASINI, TECO
Entity type:Individual
Prefix:
First Name:TECO
Middle Name:
Last Name:GERVASINI
Suffix:
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 1:12029 29TH RD
Mailing Address - Street 2:
Mailing Address - City:WELLBORN
Mailing Address - State:FL
Mailing Address - Zip Code:32094-2037
Mailing Address - Country:US
Mailing Address - Phone:386-288-1503
Mailing Address - Fax:
Practice Address - Street 1:12029 29TH RD
Practice Address - Street 2:
Practice Address - City:WELLBORN
Practice Address - State:FL
Practice Address - Zip Code:32094-2037
Practice Address - Country:US
Practice Address - Phone:386-288-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL614627Medicaid