Healthcare Provider Details

I. General information

NPI: 1891010054
Provider Name (Legal Business Name): PHILLINE JAWID MOPAS RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4166 TAMIAMI TRL SUITE A
PORT CHARLOTTE FL
33952-9209
US

IV. Provider business mailing address

4166 TAMIAMI TRL SUITE A
PORT CHARLOTTE FL
33952-9209
US

V. Phone/Fax

Practice location:
  • Phone: 941-766-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 25073
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: