Provider Demographics
NPI:1518054758
Name:DUNN AVENUE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:DUNN AVENUE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:REIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERVELDE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-751-6646
Mailing Address - Street 1:2377 DUNN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6984
Mailing Address - Country:US
Mailing Address - Phone:904-751-6646
Mailing Address - Fax:904-751-6647
Practice Address - Street 1:2377 DUNN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6983
Practice Address - Country:US
Practice Address - Phone:904-751-6646
Practice Address - Fax:904-751-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686550Medicare ID - Type Unspecified
FL686550Medicare Oscar/Certification