Provider Demographics
NPI:1578878450
Name:PHYSIONETICS LLC
Entity Type:Organization
Organization Name:PHYSIONETICS LLC
Other - Org Name:PHYSIONETICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLA
Authorized Official - Middle Name:KHALAF
Authorized Official - Last Name:VARVERIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:239-593-4348
Mailing Address - Street 1:1575 PINE RIDGE RD STE 15
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-2110
Mailing Address - Country:US
Mailing Address - Phone:239-593-4348
Mailing Address - Fax:239-593-4387
Practice Address - Street 1:1575 PINE RIDGE RD STE 15
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2110
Practice Address - Country:US
Practice Address - Phone:239-593-4348
Practice Address - Fax:239-593-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10624261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy