Provider Demographics
NPI:1053129353
Name:VELASCO, LANCE (PT, DPT)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4312
Mailing Address - Country:US
Mailing Address - Phone:904-345-7251
Mailing Address - Fax:
Practice Address - Street 1:2616 S HWY 27
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6526
Practice Address - Country:US
Practice Address - Phone:352-565-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty