Provider Demographics
NPI:1457637498
Name:GOLDEN PROFESSIONAL THERAPY CORP
Entity Type:Organization
Organization Name:GOLDEN PROFESSIONAL THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARNALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-4001
Mailing Address - Street 1:31 BARKLEY CIR
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7628
Mailing Address - Country:US
Mailing Address - Phone:239-931-4001
Mailing Address - Fax:239-931-4002
Practice Address - Street 1:31 BARKLEY CIR
Practice Address - Street 2:SUITE 1B
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7628
Practice Address - Country:US
Practice Address - Phone:239-931-4001
Practice Address - Fax:239-931-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101292208D00000X
FLMA63547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000107700Medicaid