Provider Demographics
NPI:1134885148
Name:FQ0016, LLC
Entity type:Organization
Organization Name:FQ0016, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-451-4921
Mailing Address - Street 1:3657 CORTEZ RD W STE 110
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3171
Mailing Address - Country:US
Mailing Address - Phone:239-451-4922
Mailing Address - Fax:239-451-4921
Practice Address - Street 1:18900 N TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-7312
Practice Address - Country:US
Practice Address - Phone:239-451-4922
Practice Address - Fax:239-451-4921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-14
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy