Provider Demographics
NPI:1073085734
Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. PETERSBURG, LLC
Entity Type:Organization
Organization Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. PETERSBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:813-690-4414
Mailing Address - Street 1:21756 STATE ROAD 54 STE 102
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2905
Mailing Address - Country:US
Mailing Address - Phone:727-475-5580
Mailing Address - Fax:844-213-8986
Practice Address - Street 1:2600 DR MARTIN LUTHER KING JR ST N STE 200B
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-2744
Practice Address - Country:US
Practice Address - Phone:727-474-5580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2019-12-09
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
FLPT19911OtherPT LICENSE