Provider Demographics
NPI:1184974586
Name:CARROLL, BURL EDWIN JR (PT)
Entity type:Individual
Prefix:
First Name:BURL
Middle Name:EDWIN
Last Name:CARROLL
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1113
Mailing Address - Street 2:
Mailing Address - City:CARYVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32425-1113
Mailing Address - Country:US
Mailing Address - Phone:850-547-2030
Mailing Address - Fax:
Practice Address - Street 1:1414 MAIN ST STE 3A
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-6951
Practice Address - Country:US
Practice Address - Phone:850-638-3387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y3434ZMedicare UPIN