Provider Demographics
NPI:1790842854
Name:WELLINGTON PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:WELLINGTON PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVOLACCI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-793-5550
Mailing Address - Street 1:12797 W. FOREST HILL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-793-5550
Mailing Address - Fax:561-793-5788
Practice Address - Street 1:12797 W. FOREST HILL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-793-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10273111N00000X
FLPT21779225100000X
FLPT27611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8947Medicare ID - Type Unspecified