Healthcare Provider Details

I. General information

NPI: 1730826769
Provider Name (Legal Business Name): KARL A BOURNE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/20/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17601 NW 2ND AVE STE S
MIAMI FL
33169-5001
US

IV. Provider business mailing address

22901 SW 88TH PL UNIT 101
CUTLER BAY FL
33190-2031
US

V. Phone/Fax

Practice location:
  • Phone: 305-770-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number38647
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: