Provider Demographics
NPI:1619704228
Name:VIZCARRONDO, CARLOS R (COTA/L)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:VIZCARRONDO
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HEARTHSIDE AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-6822
Mailing Address - Country:US
Mailing Address - Phone:321-576-5068
Mailing Address - Fax:
Practice Address - Street 1:123 HEARTHSIDE AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-6822
Practice Address - Country:US
Practice Address - Phone:321-576-5068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA20036224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty