1407215254 NPI number — OLIVE TREE PHYSICAL THERAPY, LLC

Table of content: (NPI 1407215254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407215254 NPI number — OLIVE TREE PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLIVE TREE PHYSICAL THERAPY, 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:
1407215254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 CABANA BLVD
Provider Second Line Business Mailing Address:
UNIT 1103
Provider Business Mailing Address City Name:
PANAMA CITY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32407-4563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2810 HIGHWAY 77
Provider Second Line Business Practice Location Address:
D
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-4479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-779-3119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TOMES
Authorized Official First Name:
SHIMIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-779-3119

Provider Taxonomy Codes

  • Taxonomy code: 261QR0401X , with the licence number:  PT26256 , 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)





Copyright © 2007-2025 www.npivalidator.com