MEDICARE: PT & SPINAL REHAB

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	PT27107	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1942608187	OTHER	FL	MEDICARE INDIVIDUAL NPI

General Provider Information

NPI Number	:	1871974683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PT & SPINAL REHAB

Provider Business Mailing Address
First Line	:	17521 US HIGHWAY 441
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6737
Country	:	US
Telephone Number	:	352-735-4385
Fax Number	:	352-735-4386

Provider Business Practice Location Address
First Line	:	17521 US HIGHWAY 441
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6737
Country	:	US
Telephone Number	:	352-735-4385
Fax Number	:	352-735-4386

Authorized Official
Title or Position	:	OWNER
Name	:	DANIEL JOSEPH THOMAS
Credential	:	PT
Telephone Number	:	352-735-4385

Provider Enumeration Date	:	06/17/2015
Last Update Date	:	06/17/2015

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Directions to “PT & SPINAL REHAB ” Practice Location

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