Provider Demographics
NPI:1710945704
Name:FARESE PHYSICAL THERAPY CENTER, INC
Entity Type:Organization
Organization Name:FARESE PHYSICAL THERAPY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FARESE
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, MBA, PT, CHT
Authorized Official - Phone:727-209-4545
Mailing Address - Street 1:7005 FOURTH STREET NORTH
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702
Mailing Address - Country:US
Mailing Address - Phone:727-209-4545
Mailing Address - Fax:727-209-4546
Practice Address - Street 1:7005 FOURTH STREET NORTH
Practice Address - Street 2:SUITE 4
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-209-4545
Practice Address - Fax:727-209-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4310261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886130700Medicaid
FL106792Medicare ID - Type Unspecified