Provider Demographics
NPI:1780239392
Name:BACH-RANDOLPH, JASON ROBERT
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:BACH-RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:ROBERT
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 E OLYMPIA AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3838
Mailing Address - Country:US
Mailing Address - Phone:941-575-7300
Mailing Address - Fax:941-505-7301
Practice Address - Street 1:530 E OLYMPIA AVE STE 112
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3838
Practice Address - Country:US
Practice Address - Phone:941-575-7300
Practice Address - Fax:941-505-7301
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34952OtherPT LICENSE