Provider Demographics
NPI:1619169661
Name:PALATKA PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PALATKA PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:FRISVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:913-387-0679
Mailing Address - Street 1:3715 CRILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-9168
Mailing Address - Country:US
Mailing Address - Phone:913-387-0679
Mailing Address - Fax:913-387-0879
Practice Address - Street 1:3715 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-9168
Practice Address - Country:US
Practice Address - Phone:913-387-0679
Practice Address - Fax:913-387-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1810605OtherAETNA HMO
FL9120138OtherAETNA PPO
FLAI074Medicare PIN