Provider Demographics
NPI:1710040159
Name:PHYSICAL THERAPY AND REHABIITATION CLINIC INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AND REHABIITATION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WELDON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-259-8343
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-272-2830
Mailing Address - Fax:904-272-8814
Practice Address - Street 1:31 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2301
Practice Address - Country:US
Practice Address - Phone:904-259-8343
Practice Address - Fax:904-272-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
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
FL106524Medicare ID - Type Unspecified