Healthcare Provider Details

I. General information

NPI: 1902195506
Provider Name (Legal Business Name): AGEWELL SOUTH PHYSICAL THERAPY AND WELLNESS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 W ATLANTIC AVE
DELRAY BEACH FL
33484-8103
US

IV. Provider business mailing address

223 RIDGE RD
DOUGLASTON NY
11363-1308
US

V. Phone/Fax

Practice location:
  • Phone: 914-318-1304
  • Fax:
Mailing address:
  • Phone: 914-318-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT 26314
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN DRAGAN
Title or Position: CO-OWNER
Credential: PT
Phone: 914-318-1304