Provider Demographics
NPI:1124224795
Name:PROFESSIONAL LYMPHEDEMA SERVICES INC
Entity Type:Organization
Organization Name:PROFESSIONAL LYMPHEDEMA SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HANAK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:386-882-1161
Mailing Address - Street 1:3131 VICTORY PALM DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-6129
Mailing Address - Country:US
Mailing Address - Phone:386-882-1161
Mailing Address - Fax:
Practice Address - Street 1:2568 S RIDGEWOOD AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-5980
Practice Address - Country:US
Practice Address - Phone:386-423-9322
Practice Address - Fax:386-423-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE3356OtherPHYSICAL THERAPY
FL7809762OtherPHYSICAL THERAPY
FLK7588Medicare ID - Type UnspecifiedPHYSICAL THERAPY