MEDICARE: PURE PT PHYSICAL THERAPY 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

General Provider Information

NPI Number	:	1417633868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE PT PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	2864 WELLNESS AVE STE 100
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8335
Country	:	US
Telephone Number	:	386-575-4027
Fax Number	:	386-575-4028

Provider Business Practice Location Address
First Line	:	2864 WELLNESS AVE STE 100
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8335
Country	:	US
Telephone Number	:	386-575-4027
Fax Number	:	386-575-4028

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	DR. PAUL KUDLICK
Credential	:	PT, DPT
Telephone Number	:	386-575-4027

Provider Enumeration Date	:	06/22/2023
Last Update Date	:	06/22/2023

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