Provider Demographics
NPI:1750400479
Name:PALACIO, CARMEN (PT)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:PALACIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 NW 114TH AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4374
Mailing Address - Country:US
Mailing Address - Phone:786-621-7860
Mailing Address - Fax:786-621-7861
Practice Address - Street 1:4005 NW 114TH AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4374
Practice Address - Country:US
Practice Address - Phone:786-621-7860
Practice Address - Fax:786-621-7861
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7029AMedicare ID - Type Unspecified