Provider Demographics
NPI:1235324005
Name:FAMILY PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:FAMILY PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANIESSE
Authorized Official - Middle Name:O
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:813-654-3808
Mailing Address - Street 1:704 W LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6260
Mailing Address - Country:US
Mailing Address - Phone:813-654-3808
Mailing Address - Fax:
Practice Address - Street 1:704 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6260
Practice Address - Country:US
Practice Address - Phone:813-654-3808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0005096261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY2893Medicare PIN