Provider Demographics
NPI:1902195506
Name:AGEWELL SOUTH PHYSICAL THERAPY AND WELLNESS PA
Entity Type:Organization
Organization Name:AGEWELL SOUTH PHYSICAL THERAPY AND WELLNESS PA
Other - Org Name:AGEWELL SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:914-318-1304
Mailing Address - Street 1:223 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1308
Mailing Address - Country:US
Mailing Address - Phone:914-318-1304
Mailing Address - Fax:
Practice Address - Street 1:5180 W ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8103
Practice Address - Country:US
Practice Address - Phone:914-318-1304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 263142251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty