Provider Demographics
NPI:1134292253
Name:MAINSTREAM PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MAINSTREAM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:STEPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSM MPT
Authorized Official - Phone:239-415-2595
Mailing Address - Street 1:9371 CYPRESS LAKE DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4939
Mailing Address - Country:US
Mailing Address - Phone:239-415-2595
Mailing Address - Fax:239-415-2597
Practice Address - Street 1:9371 CYPRESS LAKE DR
Practice Address - Street 2:SUITE 20
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4939
Practice Address - Country:US
Practice Address - Phone:239-415-2595
Practice Address - Fax:239-415-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
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
FLK7849Medicare UPIN