1043246580 NPI number — PONTE VEDRA PHYSICAL THERAPY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043246580 NPI number — PONTE VEDRA PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONTE VEDRA PHYSICAL THERAPY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043246580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 48116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32247-8116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-725-1657
Provider Business Mailing Address Fax Number:
904-725-7247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 A1A N
Provider Second Line Business Practice Location Address:
SUITE 18A
Provider Business Practice Location Address City Name:
PONTE VEDRA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32082-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-285-2910
Provider Business Practice Location Address Fax Number:
904-285-4663
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-285-2910

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R9F . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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