Provider Demographics
NPI:1174164859
Name:LIAO, PEI-WEN (LAC)
Entity type:Individual
Prefix:
First Name:PEI-WEN
Middle Name:
Last Name:LIAO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 S VOLUSIA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9134
Mailing Address - Country:US
Mailing Address - Phone:386-774-6333
Mailing Address - Fax:386-410-1603
Practice Address - Street 1:2501 S VOLUSIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9134
Practice Address - Country:US
Practice Address - Phone:386-774-6333
Practice Address - Fax:386-410-1603
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4097171100000X
FLPT33485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT33485OtherSTATE OF FLORIDA
FLAP4097OtherSTATE OF FLORIDA