Provider Demographics
NPI:1689704439
Name:TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
Other - Org Name:THERAPY SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:KNISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:850-877-8855
Mailing Address - Street 1:3334 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8405
Mailing Address - Country:US
Mailing Address - Phone:850-219-1520
Mailing Address - Fax:850-201-3369
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8405
Practice Address - Country:US
Practice Address - Phone:850-219-1523
Practice Address - Fax:850-201-3369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883224204Medicaid
FL4606650001Medicare NSC
FL106822Medicare ID - Type Unspecified