Provider Demographics
NPI:1043815392
Name:BOOST PT
Entity Type:Organization
Organization Name:BOOST PT
Other - Org Name:BOOST PHYSIOTHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL GERALD
Authorized Official - Middle Name:PLANA
Authorized Official - Last Name:BARROS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:904-315-2881
Mailing Address - Street 1:1093 A1A BEACH BLVD # 198
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6733
Mailing Address - Country:US
Mailing Address - Phone:904-770-1481
Mailing Address - Fax:904-615-9993
Practice Address - Street 1:150 SOUTHPARK BLVD STE 204D
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5179
Practice Address - Country:US
Practice Address - Phone:904-770-1481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty