Provider Demographics
NPI:1558511725
Name:PELICAN SPORTS & REHABILITATION OF NAPLES
Entity Type:Organization
Organization Name:PELICAN SPORTS & REHABILITATION OF NAPLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:239-591-4711
Mailing Address - Street 1:9051 N TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2520
Mailing Address - Country:US
Mailing Address - Phone:239-591-4711
Mailing Address - Fax:239-593-1195
Practice Address - Street 1:9051 N TAMIAMI TRAIL
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-2520
Practice Address - Country:US
Practice Address - Phone:239-591-4711
Practice Address - Fax:239-593-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBU319AMedicare PIN