Provider Demographics
NPI:1316104292
Name:DOCUMENTO, MARK (RPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DOCUMENTO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7666
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-7666
Mailing Address - Country:US
Mailing Address - Phone:772-408-6630
Mailing Address - Fax:772-408-6750
Practice Address - Street 1:266 NW PEACOCK BLVD
Practice Address - Street 2:SUITE 2-204 BLDG. 2
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2271
Practice Address - Country:US
Practice Address - Phone:772-408-6630
Practice Address - Fax:772-408-6750
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBK828ZOtherPROVIDER TRANSACTION ACCESS NUMBER