Healthcare Provider Details

I. General information

NPI: 1366994519
Provider Name (Legal Business Name): PHI-THERAS REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12450 TAMIAMI TRL S SUITE E
NORTH PORT FL
34287-1473
US

IV. Provider business mailing address

12450 TAMIAMI TRL S SUITE E
NORTH PORT FL
34287-1473
US

V. Phone/Fax

Practice location:
  • Phone: 941-257-4763
  • Fax: 941-257-4766
Mailing address:
  • Phone: 941-257-4763
  • Fax: 941-257-4766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT29353
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT29353
License Number StateFL

VIII. Authorized Official

Name: JORDAN SERRANO
Title or Position: PRESIDENT
Credential: PT
Phone: 941-257-4763