Provider Demographics
NPI:1821564816
Name:BANYAN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BANYAN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-317-1872
Mailing Address - Street 1:2324 S CONGRESS AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7667
Mailing Address - Country:US
Mailing Address - Phone:561-408-0903
Mailing Address - Fax:
Practice Address - Street 1:2324 S CONGRESS AVE STE 1A
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-7667
Practice Address - Country:US
Practice Address - Phone:561-408-0903
Practice Address - Fax:561-408-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy