Provider Demographics
NPI:1164792073
Name:MCCORMACK, CHRISTOPHER (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 JUPITER LAKES BLVD
Mailing Address - Street 2:SUITE 5101
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7191
Mailing Address - Country:US
Mailing Address - Phone:561-741-1876
Mailing Address - Fax:888-721-1997
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:SUITE 5101
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-741-1876
Practice Address - Fax:888-721-1997
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22813225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant