Provider Demographics
NPI:1003830324
Name:PAYNE, JOHN L (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 75TH AVE
Mailing Address - Street 2:SUNCOAST FITNESS, INC.
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706-1833
Mailing Address - Country:US
Mailing Address - Phone:727-367-0075
Mailing Address - Fax:727-367-0402
Practice Address - Street 1:575 75TH AVE
Practice Address - Street 2:SUNCOAST FITNESS, INC.
Practice Address - City:ST PETE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33706-1833
Practice Address - Country:US
Practice Address - Phone:727-367-0075
Practice Address - Fax:727-367-0402
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 28370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid
LA1174173Medicaid