Provider Demographics
NPI:1043205925
Name:PERSONAL PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PERSONAL PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUALLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:954-599-8359
Mailing Address - Street 1:839 NW 98TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-6129
Mailing Address - Country:US
Mailing Address - Phone:954-599-8359
Mailing Address - Fax:954-370-8291
Practice Address - Street 1:839 NW 98TH AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-6129
Practice Address - Country:US
Practice Address - Phone:954-599-8359
Practice Address - Fax:954-370-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 8870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9654AMedicare ID - Type UnspecifiedDWIGHT A QUALLO, PT
FLK3912Medicare ID - Type UnspecifiedORIGINAL GROUP ID NUMBER