Provider Demographics
NPI:1376597849
Name:ADVANCED PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:321-676-2055
Mailing Address - Street 1:6050 BABCOCK ST SE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-3996
Mailing Address - Country:US
Mailing Address - Phone:321-676-2055
Mailing Address - Fax:321-676-9928
Practice Address - Street 1:6050 BABCOCK ST SE
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-3996
Practice Address - Country:US
Practice Address - Phone:321-676-2055
Practice Address - Fax:321-676-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 5799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY3810OtherBCBS
FLK0715Medicare ID - Type Unspecified