Provider Demographics
NPI:1740533603
Name:CHURCHILL, ROBERT (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CHURCHILL
Suffix:
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 1:1120 ROLLING STONE RUN
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-6033
Mailing Address - Country:US
Mailing Address - Phone:813-240-9356
Mailing Address - Fax:
Practice Address - Street 1:1120 ROLLING STONE RUN
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-6033
Practice Address - Country:US
Practice Address - Phone:813-240-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist