Healthcare Provider Details

I. General information

NPI: 1063997260
Provider Name (Legal Business Name): KNEADED THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2746 E COMMERICAL BLVD.
FT. LAUDERDALE FL
33308
US

IV. Provider business mailing address

2746 E COMMERICAL BLVD.
FT. LAUDERDALE FL
33308
US

V. Phone/Fax

Practice location:
  • Phone: 954-772-2977
  • Fax: 954-772-2928
Mailing address:
  • Phone: 954-772-2977
  • Fax: 954-772-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTEN TRUJILLO
Title or Position: OWNER/LMT
Credential: LMT
Phone: 954-772-2977