Provider Demographics
NPI:1881083475
Name:MAXWELLNESS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:MAXWELLNESS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:PASCAL
Authorized Official - Last Name:PRADEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:954-558-3462
Mailing Address - Street 1:18600 NW 87TH AVE UNIT 126
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3536
Mailing Address - Country:US
Mailing Address - Phone:954-869-4310
Mailing Address - Fax:954-869-4313
Practice Address - Street 1:18600 NW 87TH AVE UNIT 126
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3536
Practice Address - Country:US
Practice Address - Phone:954-869-4310
Practice Address - Fax:954-869-4313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20304261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT20304OtherMEDICAL LICENSE
FL890766800Medicaid