Provider Demographics
NPI:1174049977
Name:VAZ, RICARDO (LPTA)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:VAZ
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 DORIS DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-4103
Mailing Address - Country:US
Mailing Address - Phone:386-597-3992
Mailing Address - Fax:
Practice Address - Street 1:701 E 3RD AVE UNIT 6
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-3104
Practice Address - Country:US
Practice Address - Phone:386-597-3992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27805225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant