Healthcare Provider Details

I. General information

NPI: 1316970114
Provider Name (Legal Business Name): ROBERT LANCE WHORTON PT, MS, MTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S MAIN ST
CRESTVIEW FL
32536-3737
US

IV. Provider business mailing address

210 S MAIN ST
CRESTVIEW FL
32536-3737
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 850-226-6801
  • Fax: 877-413-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070006780
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT29006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: