MEDICARE: MR. LESLIE ETTLINGER PT

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	PT4722	FL

General Provider Information

NPI Number	:	1295990026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LESLIE ETTLINGER PT

Provider Business Mailing Address
First Line	:	1509 RODMAN ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6437
Country	:	US
Telephone Number	:	954-922-0265
Fax Number	:	954-922-0265

Provider Business Practice Location Address
First Line	:	4800 N FEDERAL HWY
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4606
Country	:	US
Telephone Number	:	954-358-0855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	07/21/2008

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