Provider Demographics
NPI:1023677630
Name:PHYSICAL THERAPY WELLNESS GROUP
Entity type:Organization
Organization Name:PHYSICAL THERAPY WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPERANCIA
Authorized Official - Middle Name:ANNA
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:772-209-1183
Mailing Address - Street 1:10380 SW VILLAGE CENTER DR # 355
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-1931
Mailing Address - Country:US
Mailing Address - Phone:772-209-1183
Mailing Address - Fax:
Practice Address - Street 1:519 SW NAGLE PLACE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-209-1183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261Q00000XMedicaid