Provider Demographics
NPI:1265724330
Name:PREMIER PHYSICAL THERAPY & SPORTS MEDICINE
Entity type:Organization
Organization Name:PREMIER PHYSICAL THERAPY & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:772-335-7966
Mailing Address - Street 1:897 NE JENSEN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4799
Mailing Address - Country:US
Mailing Address - Phone:772-324-3080
Mailing Address - Fax:772-335-7963
Practice Address - Street 1:897 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4799
Practice Address - Country:US
Practice Address - Phone:772-324-3080
Practice Address - Fax:772-335-7963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty