Provider Demographics
NPI:1114679040
Name:MOVEMENT DRIVEN PERFORMANCE PHYSIOTHERAPY
Entity Type:Organization
Organization Name:MOVEMENT DRIVEN PERFORMANCE PHYSIOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:786-201-3825
Mailing Address - Street 1:44 SPARROW SONG PL
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-7590
Mailing Address - Country:US
Mailing Address - Phone:786-201-3825
Mailing Address - Fax:
Practice Address - Street 1:44 SPARROW SONG PL
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-7590
Practice Address - Country:US
Practice Address - Phone:786-201-3825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy