Provider Demographics
NPI:1497898688
Name:PRODIGY HEALTHCARE SPECIALISTS, INC.
Entity Type:Organization
Organization Name:PRODIGY HEALTHCARE SPECIALISTS, INC.
Other - Org Name:PRODIGY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:RELAO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:941-729-8600
Mailing Address - Street 1:2823 US HIGHWAY 301 N
Mailing Address - Street 2:STE. 4
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-2084
Mailing Address - Country:US
Mailing Address - Phone:941-729-8600
Mailing Address - Fax:941-729-4440
Practice Address - Street 1:2823 US HIGHWAY 301 N
Practice Address - Street 2:STE. 4
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2084
Practice Address - Country:US
Practice Address - Phone:941-729-8600
Practice Address - Fax:941-729-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11333261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY905GOtherBCBS OF FLORIDA
FLY905GOtherBCBS OF FLORIDA