Provider Demographics
NPI:1407215254
Name:OLIVE TREE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:OLIVE TREE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:704-779-3119
Mailing Address - Street 1:300 CABANA BLVD
Mailing Address - Street 2:UNIT 1103
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-4563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2810 HIGHWAY 77
Practice Address - Street 2:D
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4479
Practice Address - Country:US
Practice Address - Phone:704-779-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26256261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1538414321Medicare PIN