Provider Demographics
NPI:1366786287
Name:CICERON, STANLEY
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:CICERON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 DAVIE BLVD APT 244
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-3126
Mailing Address - Country:US
Mailing Address - Phone:516-864-3608
Mailing Address - Fax:
Practice Address - Street 1:2113 DAVIE BLVD APT 244
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33312-3126
Practice Address - Country:US
Practice Address - Phone:516-864-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23764225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23764OtherSTATE OF FLORIDA DEPT OF HEALTH