Provider Demographics
NPI:1831156785
Name:PORTWOOD, ANTHONY CRAIG (MS, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:CRAIG
Last Name:PORTWOOD
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 CALLE GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-7445
Mailing Address - Country:US
Mailing Address - Phone:386-677-4651
Mailing Address - Fax:386-677-6030
Practice Address - Street 1:1151 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5912
Practice Address - Country:US
Practice Address - Phone:386-677-6455
Practice Address - Fax:386-677-6030
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer