1710040159 NPI number — PHYSICAL THERAPY AND REHABIITATION CLINIC INC

Table of content: (NPI 1710040159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710040159 NPI number — PHYSICAL THERAPY AND REHABIITATION CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY AND REHABIITATION CLINIC 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:
1710040159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2140 KINGSLEY AVE
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-5180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-272-2830
Provider Business Mailing Address Fax Number:
904-272-8814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 S 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACCLENNY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32063-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-259-8343
Provider Business Practice Location Address Fax Number:
904-272-8814
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WELDON
Authorized Official First Name:
DAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-259-8343

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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