Healthcare Provider Details

I. General information

NPI: 1417957358
Provider Name (Legal Business Name): PALM HARBOR PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30522 US HIGHWAY 19 N SUITE 110
PALM HARBOR FL
34684-4444
US

IV. Provider business mailing address

30522 US HIGHWAY 19 N SUITE 110
PALM HARBOR FL
34684-4444
US

V. Phone/Fax

Practice location:
  • Phone: 727-789-6008
  • Fax: 727-789-0716
Mailing address:
  • Phone: 727-789-6008
  • Fax: 727-789-0716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4811
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA2119
License Number StateFL

VIII. Authorized Official

Name: MR. ANDREW N LOSCALZO
Title or Position: ADMINISTRATOR
Credential: PT, DPT, ATC
Phone: 727-789-6008