Provider Demographics
NPI:1659164796
Name:ANTONIO, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ANTONIO
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 1:3716 BOLDING CIR
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3054
Mailing Address - Country:US
Mailing Address - Phone:770-561-3206
Mailing Address - Fax:
Practice Address - Street 1:1021 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5252
Practice Address - Country:US
Practice Address - Phone:706-778-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer