Provider Demographics
NPI:1407122682
Name:JC PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:JC PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-593-9333
Mailing Address - Street 1:3900 NW 79TH AVE
Mailing Address - Street 2:SUITE 807
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6556
Mailing Address - Country:US
Mailing Address - Phone:305-593-9333
Mailing Address - Fax:305-593-9089
Practice Address - Street 1:3900 NW 79TH AVE
Practice Address - Street 2:SUITE 807
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6556
Practice Address - Country:US
Practice Address - Phone:305-593-9333
Practice Address - Fax:305-593-9089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-01
Last Update Date:2012-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8991261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy