Provider Demographics
NPI:1487094983
Name:JAESEN PETRETTA INC
Entity type:Organization
Organization Name:JAESEN PETRETTA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAESEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:239-839-3408
Mailing Address - Street 1:4281 7TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-4029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12995 S CLEVELAND AVE STE 158
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3867
Practice Address - Country:US
Practice Address - Phone:239-839-3408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10199261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation