Healthcare Provider Details

I. General information

NPI: 1952333502
Provider Name (Legal Business Name): KAHARI TAMON WOOD MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 SW FONDURA RD
PORT SAINT LUCIE FL
34953-2773
US

IV. Provider business mailing address

2531 SW FONDURA RD
PORT SAINT LUCIE FL
34953-2773
US

V. Phone/Fax

Practice location:
  • Phone: 772-348-4272
  • Fax: 772-348-4612
Mailing address:
  • Phone: 772-348-4272
  • Fax: 772-348-4612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT21707
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: