Provider Demographics
NPI:1588385538
Name:LLANES SOROLLA, ERNESTO (PTA)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:LLANES SOROLLA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14921 SW 283RD ST APT 202
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-1583
Mailing Address - Country:US
Mailing Address - Phone:305-873-4208
Mailing Address - Fax:
Practice Address - Street 1:14921 SW 283RD ST APT 202
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-1583
Practice Address - Country:US
Practice Address - Phone:305-873-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA32292225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant