MEDICARE: BRIAN HENDRICKS PTA

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	174400000X	Specialist	PTA 19335	FL

General Provider Information

NPI Number	:	1467759175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN HENDRICKS PTA

Provider Business Mailing Address
First Line	:	4111 W MORRISON AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-4335
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4111 W MORRISON AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-4335
Country	:	US
Telephone Number	:	727-698-6175
Fax Number	:

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

Provider Enumeration Date	:	02/15/2011
Last Update Date	:	02/15/2011

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