Provider Demographics
NPI:1831277078
Name:ADVANCED INTEGRATED MANUAL PHYSICAL THERAPY, PA
Entity type:Organization
Organization Name:ADVANCED INTEGRATED MANUAL PHYSICAL THERAPY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:561-733-7677
Mailing Address - Street 1:1800 W WOOLBRIGHT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-6398
Mailing Address - Country:US
Mailing Address - Phone:561-733-7677
Mailing Address - Fax:561-733-7074
Practice Address - Street 1:1800 W WOOLBRIGHT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6398
Practice Address - Country:US
Practice Address - Phone:561-733-7677
Practice Address - Fax:561-733-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3785Medicare ID - Type UnspecifiedGROUP