Provider Demographics
NPI:1780853861
Name:BRAZIL PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BRAZIL PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RPT
Authorized Official - Prefix:MS
Authorized Official - First Name:M'LISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALDT
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:812-443-6144
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-0563
Mailing Address - Country:US
Mailing Address - Phone:812-443-6144
Mailing Address - Fax:812-443-5506
Practice Address - Street 1:117 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2622
Practice Address - Country:US
Practice Address - Phone:812-443-6144
Practice Address - Fax:812-443-5506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDC9253OtherPALMETTO GBA
IN000000255594OtherBCBS
IN000000255594OtherUNICARE
INDC9253OtherPALMETTO GBA