Healthcare Provider Details

I. General information

NPI: 1386895050
Provider Name (Legal Business Name): PRO-MOTION PHYSICAL THERAPY OF VOLUSIA CTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 S CLYDE MORRIS BLVD SUITE 1-D
PORT ORANGE FL
32129-6404
US

IV. Provider business mailing address

PO BOX 290699
PORT ORANGE FL
32129-0699
US

V. Phone/Fax

Practice location:
  • Phone: 386-492-2986
  • Fax: 386-492-2987
Mailing address:
  • Phone: 386-492-2986
  • Fax: 386-492-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7269
License Number StateFL

VIII. Authorized Official

Name: MARIE CARMEN YU
Title or Position: PRESIDENT
Credential: P.T.
Phone: 386-492-2986