1225420623 NPI number — FIVE STAR PHYSICAL THERAPY

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 1225420623 NPI number — FIVE STAR PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR PHYSICAL THERAPY
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:
1225420623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
236 PONTE VEDRA PARK DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PONTE VEDRA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32082-6619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-280-3440
Provider Business Mailing Address Fax Number:
904-280-3444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
236 PONTE VEDRA PARK DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PONTE VEDRA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32082-6619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-280-3440
Provider Business Practice Location Address Fax Number:
904-280-3444
Provider Enumeration Date:
02/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERSON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
904-280-3440

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  PT30070 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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