Provider Demographics
NPI:1912379959
Name:SELECT MEDICAL
Entity Type:Organization
Organization Name:SELECT MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIGHAM
Authorized Official - Middle Name:NATHANIEL
Authorized Official - Last Name:GRIEVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-268-4953
Mailing Address - Street 1:10680 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1000
Mailing Address - Country:US
Mailing Address - Phone:904-268-4953
Mailing Address - Fax:
Practice Address - Street 1:10680 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-1000
Practice Address - Country:US
Practice Address - Phone:904-268-4953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25570261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy