Provider Demographics
NPI:1225106404
Name:FLORIDA PHYSICAL THERAPY & WELLNESS CTR LLC
Entity Type:Organization
Organization Name:FLORIDA PHYSICAL THERAPY & WELLNESS CTR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:352-357-0091
Mailing Address - Street 1:2575 KURT ST STE 106
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6256
Mailing Address - Country:US
Mailing Address - Phone:352-357-0091
Mailing Address - Fax:352-357-0428
Practice Address - Street 1:2575 KURT ST STE 106
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6256
Practice Address - Country:US
Practice Address - Phone:352-357-0091
Practice Address - Fax:352-357-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686739Medicare ID - Type Unspecified