Provider Demographics
NPI:1295591022
Name:SUMMIT PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:SUMMIT PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:REEVES
Authorized Official - Last Name:VOLLERTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-644-7722
Mailing Address - Street 1:2219 COUNTY ROAD 220 STE 304
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-7778
Mailing Address - Country:US
Mailing Address - Phone:904-644-7722
Mailing Address - Fax:904-637-1532
Practice Address - Street 1:2140 KINGSLEY AVE STE 11
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5129
Practice Address - Country:US
Practice Address - Phone:904-592-1036
Practice Address - Fax:904-637-1532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty