Provider Demographics
NPI:1437572781
Name:FUNCTIONAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FUNCTIONAL PHYSICAL THERAPY
Other - Org Name:BRIDGE OF HOPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:L
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:AD
Authorized Official - Phone:407-575-4636
Mailing Address - Street 1:PO BOX 452878
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34745-2878
Mailing Address - Country:US
Mailing Address - Phone:407-575-4636
Mailing Address - Fax:321-250-7425
Practice Address - Street 1:1300 KEVSTIN DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5843
Practice Address - Country:US
Practice Address - Phone:407-575-4636
Practice Address - Fax:321-250-7425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FUNCTIONAL PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 21146225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9635AOtherTHERAPY GROUP