Provider Demographics
NPI:1538575881
Name:TELLEZ, EVERARDO 'LALO'
Entity type:Individual
Prefix:
First Name:EVERARDO 'LALO'
Middle Name:
Last Name:TELLEZ
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 1:411 E ORANGE ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5054
Mailing Address - Country:US
Mailing Address - Phone:863-617-9400
Mailing Address - Fax:
Practice Address - Street 1:411 E ORANGE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5054
Practice Address - Country:US
Practice Address - Phone:863-617-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA1700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant