Provider Demographics
NPI:1154181964
Name:ADAMS, MICHAEL DALE (OTC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALE
Last Name:ADAMS
Suffix:
Gender:M
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 WILLOW BRICK RD
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6009
Mailing Address - Country:US
Mailing Address - Phone:407-432-7050
Mailing Address - Fax:
Practice Address - Street 1:2130 WILLOW BRICK RD
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6009
Practice Address - Country:US
Practice Address - Phone:407-432-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-0612225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist