Provider Demographics
NPI:1508378290
Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES LAKELAND, LLC
Entity Type:Organization
Organization Name:OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES LAKELAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF COMPLIANCE, SECURITY & PRI
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-690-4414
Mailing Address - Street 1:3903 NORTHDALE BLVD STE 111W
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1853
Mailing Address - Country:US
Mailing Address - Phone:813-381-6778
Mailing Address - Fax:
Practice Address - Street 1:4525 S FLORIDA AVE STE 25
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2184
Practice Address - Country:US
Practice Address - Phone:813-381-6778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty