Basic Information
| Provider Information | |||||||||
| NPI: | 1235887795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARINO | ||||||||
| FirstName: | ZACHARY | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6903 FERN CIR | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347489553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524673112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4501 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526094000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2022 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.