Healthcare Provider Details

I. General information

NPI: 1356440523
Provider Name (Legal Business Name): REQUEST PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 MANATEE AVE W SUITE 2
BRADENTON FL
34205-4945
US

IV. Provider business mailing address

2722 MANATEE AVE W SUITE 2
BRADENTON FL
34205-4945
US

V. Phone/Fax

Practice location:
  • Phone: 941-744-9046
  • Fax:
Mailing address:
  • Phone: 941-744-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20347
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN WALZ
Title or Position: OWNER
Credential: MPT
Phone: 941-744-9046