Provider Demographics
NPI:1740508589
Name:MARIANNA PHYSICAL THERAPY
Entity type:Organization
Organization Name:MARIANNA PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:ALONZO
Authorized Official - Last Name:LAUREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-638-3387
Mailing Address - Street 1:1567 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-6948
Mailing Address - Country:US
Mailing Address - Phone:850-638-3387
Mailing Address - Fax:850-415-1967
Practice Address - Street 1:4285 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2919
Practice Address - Country:US
Practice Address - Phone:850-482-0080
Practice Address - Fax:850-482-0082
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHIPLEY PHYSICAL THERAPY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-04
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty