MEDICARE: OCOEE PHYSICAL THERAPY, INC.

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	192907	OTHER	TN	TENNCARE ID NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	686135	OTHER	TN	ACN ID NUMBER

General Provider Information

NPI Number	:	1801827902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCOEE PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	3112 OCOEE ST N
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-5382
Country	:	US
Telephone Number	:	423-559-1537
Fax Number	:	423-559-1539

Provider Business Practice Location Address
First Line	:	3112 OCOEE ST N
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-5382
Country	:	US
Telephone Number	:	423-559-1537
Fax Number	:	423-559-1539

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PHYLLIS LEE PETERSON
Credential	:	PT, CHT
Telephone Number	:	423-559-1537

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	03/15/2011

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