Provider Demographics
NPI:1649380064
Name:PREMIER PHYSICAL THERAPY SPORT MEDICINE INC
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY SPORT MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:772-335-7966
Mailing Address - Street 1:PO BOX 8600
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985
Mailing Address - Country:US
Mailing Address - Phone:772-335-7966
Mailing Address - Fax:772-335-7963
Practice Address - Street 1:519 NW LAKE WHITNEY PL
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1621
Practice Address - Country:US
Practice Address - Phone:772-621-9313
Practice Address - Fax:772-621-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK5189OtherRAILROAD MEDICARE PTAN
FLY905BOtherBCBS PROVIDER NUMBER
FL650023083OtherRAILROAD MEDICARE
FLK3262Medicare PIN