MEDICARE: OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. PETERSBURG, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT19911	OTHER	FL	PT LICENSE

General Provider Information

NPI Number	:	1073085734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES ST. PETERSBURG, LLC

Provider Business Mailing Address
First Line	:	21756 STATE ROAD 54 STE 102
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33549-2905
Country	:	US
Telephone Number	:	727-475-5580
Fax Number	:	844-213-8986

Provider Business Practice Location Address
First Line	:	2600 DR MARTIN LUTHER KING JR ST N STE 200B
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33704-2744
Country	:	US
Telephone Number	:	727-474-5580
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BETH PATTERSON
Credential	:	PT
Telephone Number	:	813-690-4414

Provider Enumeration Date	:	12/19/2018
Last Update Date	:	12/09/2019

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