1437456167 NPI number — OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES PALM HARBOR LLC

Table of content: (NPI 1437456167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437456167 NPI number — OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES PALM HARBOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES PALM HARBOR 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1437456167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21756 STATE ROAD 54 STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33549-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-475-5540
Provider Business Mailing Address Fax Number:
844-927-4950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35095 US 19 N STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34684-1968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-475-5538
Provider Business Practice Location Address Fax Number:
844-213-8986
Provider Enumeration Date:
02/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PATTERSON
Authorized Official First Name:
BETH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CHIEF OF COMPLIANCE
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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