Provider Demographics
NPI:1033994330
Name:MODERN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MODERN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLAKE FRANCES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:954-295-1253
Mailing Address - Street 1:151 NE 16TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3882
Mailing Address - Country:US
Mailing Address - Phone:954-295-1253
Mailing Address - Fax:
Practice Address - Street 1:151 NE 16TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3882
Practice Address - Country:US
Practice Address - Phone:954-295-1253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty