Healthcare Provider Details

I. General information

NPI: 1356172506
Provider Name (Legal Business Name): CHARLES LWIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 N JASMINE AVE
TARPON SPRINGS FL
34689-5235
US

IV. Provider business mailing address

2919 WYCOMBE WAY
PALM HARBOR FL
34685-1300
US

V. Phone/Fax

Practice location:
  • Phone: 727-743-1953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number29519
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: