Provider Demographics
NPI:1417350588
Name:MAXWELLNESS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MAXWELLNESS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSCIAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:PASCAL
Authorized Official - Last Name:PRADEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:954-558-3462
Mailing Address - Street 1:20025 NW 65TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2138
Mailing Address - Country:US
Mailing Address - Phone:954-558-3462
Mailing Address - Fax:
Practice Address - Street 1:20025 NW 65TH CT
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2138
Practice Address - Country:US
Practice Address - Phone:954-558-3462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890766800Medicaid
FL890766800Medicaid