Healthcare Provider Details

I. General information

NPI: 1134059280
Provider Name (Legal Business Name): BOLT PERFORMANCE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 SW 81ST DR STE 180
MIAMI FL
33143-6603
US

IV. Provider business mailing address

390 NE 191ST ST STE 51322
MIAMI FL
33179-3899
US

V. Phone/Fax

Practice location:
  • Phone: 305-420-8265
  • Fax:
Mailing address:
  • Phone: 305-420-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN DAGES
Title or Position: OWNER
Credential:
Phone: 305-420-8265