Healthcare Provider Details

I. General information

NPI: 1619198470
Provider Name (Legal Business Name): GLENN CRAIG SAMPSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 JENSEN BEACH BLVD
JENSEN BEACH FL
34957
US

IV. Provider business mailing address

2101 SE HERRON AVENUE
PORT ST LUCIE FL
34952
US

V. Phone/Fax

Practice location:
  • Phone: 772-225-8908
  • Fax: 772-225-0843
Mailing address:
  • Phone: 772-225-8908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: