1174831523 NPI number — OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. JOES LLC

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 1174831523 NPI number — OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. JOES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. JOES LLC
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:
1174831523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6023 HAMMOCK WOODS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33556-3330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-690-4414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 W DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-805-8108
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PATTERSON
Authorized Official First Name:
BETH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
813-690-4414

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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