Provider Demographics
NPI:1114995891
Name:ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ROULEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:863-644-0007
Mailing Address - Street 1:4720 CLEVELAND HEIGHTS BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2243
Mailing Address - Country:US
Mailing Address - Phone:863-644-0007
Mailing Address - Fax:863-644-3377
Practice Address - Street 1:4720 CLEVELAND HEIGHTS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2243
Practice Address - Country:US
Practice Address - Phone:863-644-0007
Practice Address - Fax:863-644-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY917EOtherBCBS GROUP NUMBER
FLY917EOtherBCBS GROUP NUMBER