Provider Demographics
NPI:1043246580
Name:PONTE VEDRA PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PONTE VEDRA PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-285-2910
Mailing Address - Street 1:PO BOX 48116
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-8116
Mailing Address - Country:US
Mailing Address - Phone:904-725-1657
Mailing Address - Fax:904-725-7247
Practice Address - Street 1:880 A1A N
Practice Address - Street 2:SUITE 18A
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3221
Practice Address - Country:US
Practice Address - Phone:904-285-2910
Practice Address - Fax:904-285-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR9FOtherBCBS
FLR9FOtherBCBS