Provider Demographics
NPI:1235528480
Name:PHYSIQUE PHYSICAL THERAPY PERSONAL TRAINING LLC
Entity Type:Organization
Organization Name:PHYSIQUE PHYSICAL THERAPY PERSONAL TRAINING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:E
Authorized Official - Last Name:PACIFIC
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:813-466-5467
Mailing Address - Street 1:5820 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-4614
Mailing Address - Country:US
Mailing Address - Phone:813-466-5467
Mailing Address - Fax:888-475-1151
Practice Address - Street 1:5820 S 5TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-4614
Practice Address - Country:US
Practice Address - Phone:813-466-5467
Practice Address - Fax:888-475-1151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty