Provider Demographics
NPI:1497810535
Name:SOUTH WALTON PHYSICAL THERAPY AND REHABILITATION, INC
Entity Type:Organization
Organization Name:SOUTH WALTON PHYSICAL THERAPY AND REHABILITATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:V
Authorized Official - Last Name:MONTELEONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-267-9010
Mailing Address - Street 1:4942 US HIGHWAY 98 W STE 6
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-4092
Mailing Address - Country:US
Mailing Address - Phone:850-267-9010
Mailing Address - Fax:850-267-0677
Practice Address - Street 1:4942 US HIGHWAY 98 W STE 6
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-4092
Practice Address - Country:US
Practice Address - Phone:850-267-9010
Practice Address - Fax:850-267-0677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT3883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRG5OtherSRB BCBS PROV#
FLRR2OtherDFS BCBS PROV#
FL7446067OtherJESS'S AETNA PROV#
FLRG5OtherSRB BCBS PROV#