Provider Demographics
NPI:1780791442
Name:ESPENILLA, ROOSEVELT
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:ESPENILLA
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 1:7814 OAK GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7121
Mailing Address - Country:US
Mailing Address - Phone:561-963-9247
Mailing Address - Fax:
Practice Address - Street 1:12773 W FOREST HILL BLVD STE 109
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4761
Practice Address - Country:US
Practice Address - Phone:561-793-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT 9367OtherLICENSE #