Provider Demographics
NPI:1013258862
Name:PROVIDIAN FUNCTIONAL CAPACITY SPECIALISTS
Entity type:Organization
Organization Name:PROVIDIAN FUNCTIONAL CAPACITY SPECIALISTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:IMLER
Authorized Official - Suffix:
Authorized Official - Credentials:BA, AT,C/L
Authorized Official - Phone:904-982-5762
Mailing Address - Street 1:716 N ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-2920
Mailing Address - Country:US
Mailing Address - Phone:888-957-3337
Mailing Address - Fax:904-284-4244
Practice Address - Street 1:716 N ORANGE AVE
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-2920
Practice Address - Country:US
Practice Address - Phone:888-957-3337
Practice Address - Fax:904-284-4244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL1714261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy