Provider Demographics
NPI:1093399347
Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES NORTHDALE LLC
Entity Type:Organization
Organization Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES NORTHDALE LLC
Other - Org Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES CITRUS PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-475-5540
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:
Mailing Address - Fax:
Practice Address - Street 1:6633 GUNN HIGHWAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625
Practice Address - Country:US
Practice Address - Phone:727-475-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES NORTHDALE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-11
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy