Healthcare Provider Details

I. General information

NPI: 1093399347
Provider Name (Legal Business Name): OPTIMAL PERFORMANCE AND PHYSICAL THERAPIES NORTHDALE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6633 GUNN HIGHWAY
TAMPA FL
33625
US

IV. Provider business mailing address

21756 STATE ROAD 54 STE 102
LUTZ FL
33549-2905
US

V. Phone/Fax

Practice location:
  • Phone: 727-475-5540
  • Fax:
Mailing address:
  • Phone:
  • 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: BETH ANN PATTERSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 727-475-5540