Healthcare Provider Details

I. General information

NPI: 1750971032
Provider Name (Legal Business Name): UNDER THE BARBELL PHYSICAL THERAPY & PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KAYAK WAY
ST AUGUSTINE FL
32092-1202
US

IV. Provider business mailing address

105 LOMBARD WAY
SAINT AUGUSTINE FL
32092-0055
US

V. Phone/Fax

Practice location:
  • Phone: 724-977-3271
  • Fax:
Mailing address:
  • Phone: 724-977-3271
  • 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: MICHAEL JANUSKO
Title or Position: MGR
Credential: PT, DPT, MTC
Phone: 724-977-3271