Provider Demographics
NPI:1982691176
Name:RICHARD JOHANSEN PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:RICHARD JOHANSEN PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:352-372-8970
Mailing Address - Street 1:17 NW 33RD CT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2552
Mailing Address - Country:US
Mailing Address - Phone:352-372-8790
Mailing Address - Fax:352-372-8908
Practice Address - Street 1:17 NW 33RD CT
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2552
Practice Address - Country:US
Practice Address - Phone:352-372-8790
Practice Address - Fax:352-372-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY5403OtherBCBS
FLY5403ZMedicare PIN
FLK3627Medicare PIN