Healthcare Provider Details

I. General information

NPI: 1891154555
Provider Name (Legal Business Name): YOUR BODY PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2016
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 TAMIAMI TRL UNIT 111
PUNTA GORDA FL
33950-5513
US

IV. Provider business mailing address

900 TAMIAMI TRL UNIT 111
PUNTA GORDA FL
33950-5513
US

V. Phone/Fax

Practice location:
  • Phone: 941-286-6068
  • Fax:
Mailing address:
  • Phone: 941-286-6068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHRISTINA FRANCES LIPANA
Title or Position: CFO
Credential:
Phone: 941-286-6068