Provider Demographics
NPI:1508220203
Name:AZ PT INC
Entity Type:Organization
Organization Name:AZ PT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOJNO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:786-258-3763
Mailing Address - Street 1:10570 S US HIGHWAY 1
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5606
Mailing Address - Country:US
Mailing Address - Phone:771-212-7436
Mailing Address - Fax:772-212-7482
Practice Address - Street 1:10570 S US HIGHWAY 1
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5606
Practice Address - Country:US
Practice Address - Phone:772-212-7436
Practice Address - Fax:772-212-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22612261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006732700Medicaid