Provider Demographics
NPI:1356469514
Name:TALLAHASSEE PHYSICAL THERAPY AND REHABILITATION SERVICES LLC
Entity Type:Organization
Organization Name:TALLAHASSEE PHYSICAL THERAPY AND REHABILITATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOLDT
Authorized Official - Suffix:II
Authorized Official - Credentials:PT
Authorized Official - Phone:850-519-4966
Mailing Address - Street 1:1 EAGLES WAY STE 333
Mailing Address - Street 2:
Mailing Address - City:CARRABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:32322-8020
Mailing Address - Country:US
Mailing Address - Phone:850-519-4966
Mailing Address - Fax:850-942-0128
Practice Address - Street 1:132 SALEM CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2810
Practice Address - Country:US
Practice Address - Phone:850-877-8177
Practice Address - Fax:850-942-0128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024278101Medicaid
FL1462057OtherCOVENTRY HEALTHCARE OF FLORIDA
704706OtherUNITED HEALTHCARE
FL0242781Medicaid
FLIH901AMedicare PIN
FL0242781Medicaid
0978690001Medicare NSC