Healthcare Provider Details

I. General information

NPI: 1104507169
Provider Name (Legal Business Name): FORWARD PHYSIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 MAGNOLIA VIEW CT APT 202
RIVERVIEW FL
33578-4651
US

IV. Provider business mailing address

9811 MAGNOLIA VIEW CT APT 202
RIVERVIEW FL
33578-4651
US

V. Phone/Fax

Practice location:
  • Phone: 401-688-6431
  • Fax:
Mailing address:
  • Phone: 401-688-6431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS TANNER
Title or Position: DOCTOR OF PHYSICAL THERAPY
Credential: DPT
Phone: 401-688-6431