Provider Demographics
NPI:1932515376
Name:IMAGINE NEUROMUSCULAR THERAPY CENTER INC
Entity Type:Organization
Organization Name:IMAGINE NEUROMUSCULAR THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/VP
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-429-3320
Mailing Address - Street 1:2568 COMMERCE PKWY
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34289-9329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2568 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-9329
Practice Address - Country:US
Practice Address - Phone:941-429-3320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM32344174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty