Provider Demographics
NPI:1528373073
Name:PREMIERE PILATES REHABILITATION AND FITNESS
Entity Type:Organization
Organization Name:PREMIERE PILATES REHABILITATION AND FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:CHINGOON
Authorized Official - Last Name:TRISTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-315-0667
Mailing Address - Street 1:4057 SEMINOLE POINT CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5851
Mailing Address - Country:US
Mailing Address - Phone:904-797-8328
Mailing Address - Fax:
Practice Address - Street 1:4057 SEMINOLE POINT CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5851
Practice Address - Country:US
Practice Address - Phone:904-797-8328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 17260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7609YMedicare PIN