Active NPI
Mark Documento, RPT
- Physical Therapist
- Port Saint Lucie, FL
National Provider Identifier
1316104292
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- PT20821
- Practice address
- 266 NW Peacock Blvd
Suite 2-204 BLDG. 2
Port Saint Lucie, FL 34986-2271 - Phone
- (772) 408-6630
- Fax
- (772) 408-6750
- NPI assigned
- May 19, 2008
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | PT20821 | FL | Primary |
Addresses
Primary practice location
266 NW Peacock Blvd
Suite 2-204 BLDG. 2
Port Saint Lucie, FL 34986-2271
Mailing address
PO Box 7666
Port Saint Lucie, FL 34985-7666
Phone (772) 408-6630
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| BK828Z | Other | FL | PROVIDER TRANSACTION ACCESS NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT20821 | FL | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1211155200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1239235200000",
"number": "1316104292",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 7666",
"city": "PORT SAINT LUCIE",
"state": "FL",
"postal_code": "349857666",
"telephone_number": "772-408-6630",
"fax_number": "772-408-6750"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "266 NW PEACOCK BLVD",
"address_2": "SUITE 2-204 BLDG. 2",
"city": "PORT SAINT LUCIE",
"state": "FL",
"postal_code": "349862271",
"telephone_number": "772-408-6630",
"fax_number": "772-408-6750"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DOCUMENTO",
"first_name": "MARK",
"name_prefix": "Mr.",
"credential": "RPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2008-05-19",
"last_updated": "2009-04-09",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "FL",
"license": "PT20821",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PROVIDER TRANSACTION ACCESS NUMBER",
"identifier": "BK828Z",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Port Saint Lucie, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.