Healthcare Provider Details

I. General information

NPI: 1023936721
Provider Name (Legal Business Name): COPA PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 N PROSPECT AVE
LECANTO FL
34461-9792
US

IV. Provider business mailing address

1940 N PROSPECT AVE
LECANTO FL
34461-9792
US

V. Phone/Fax

Practice location:
  • Phone: 352-634-2720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIETTE GARDNER
Title or Position: OWNER/MANAGER
Credential:
Phone: 352-634-2720