Provider Demographics
NPI:1407359870
Name:PREMIER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY
Other - Org Name:PHYSICAL THERAPY NOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING/CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:FONDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-570-1666
Mailing Address - Street 1:13717 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1106
Mailing Address - Country:US
Mailing Address - Phone:305-800-3253
Mailing Address - Fax:305-203-0546
Practice Address - Street 1:13717 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-1106
Practice Address - Country:US
Practice Address - Phone:305-800-3253
Practice Address - Fax:305-203-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11471225X00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID NUMBER