Provider Demographics
NPI:1063465540
Name:CENTER IMT JACKSONVILLE FL, P.A.
Entity Type:Organization
Organization Name:CENTER IMT JACKSONVILLE FL, P.A.
Other - Org Name:CENTER IMT JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMNANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-726-0805
Mailing Address - Street 1:1840 SOUTHSIDE BLVD
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0317
Mailing Address - Country:US
Mailing Address - Phone:904-726-0805
Mailing Address - Fax:904-726-0828
Practice Address - Street 1:1840 SOUTHSIDE BLVD
Practice Address - Street 2:BUILDING 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0317
Practice Address - Country:US
Practice Address - Phone:904-726-0805
Practice Address - Fax:904-726-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
#K4862Medicare ID - Type Unspecified