Provider Demographics
NPI:1326126202
Name:AMERICAN HOME THERAPY PROVIDER INC.
Entity Type:Organization
Organization Name:AMERICAN HOME THERAPY PROVIDER INC.
Other - Org Name:CHARLOTTE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/ ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENANO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:941-766-1235
Mailing Address - Street 1:3380 TAMIAMI TRL STE C
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8156
Mailing Address - Country:US
Mailing Address - Phone:941-766-1235
Mailing Address - Fax:941-766-1644
Practice Address - Street 1:3380 TAMIAMI TRL STE C
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8156
Practice Address - Country:US
Practice Address - Phone:941-766-1235
Practice Address - Fax:941-766-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL686552261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ5DOtherBCBS FL
FLPT7217OtherLICENSE PHYSICAL THERAPY
FLPT7840OtherFL PHYSICAL THERAPY LICEN
FLQ5DOtherBCBS FL