Healthcare Provider Details

I. General information

NPI: 1952625162
Provider Name (Legal Business Name): PHYSICAL INTELLIGENCE ST. AUGUSTINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MARINE ST
ST AUGUSTINE FL
32084-5153
US

IV. Provider business mailing address

181 MOSES CREEK BLVD
ST AUGUSTINE FL
32086-5674
US

V. Phone/Fax

Practice location:
  • Phone: 904-616-1282
  • Fax: 904-342-0642
Mailing address:
  • Phone: 904-616-1282
  • Fax: 904-342-0642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number18058
License Number StateFL

VIII. Authorized Official

Name: DR. ANTONIO JOAQUIN VARELA
Title or Position: MANAGING MEMBER
Credential: DPT, PHDC
Phone: 904-616-1282