Healthcare Provider Details

I. General information

NPI: 1861919623
Provider Name (Legal Business Name): CLINTON T KHOURY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 05/12/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 EXECUTIVE DRIVE
VENICE FL
34292
US

IV. Provider business mailing address

3030 EXECUTIVE DRIVE
VENICE FL
34292
US

V. Phone/Fax

Practice location:
  • Phone: 941-485-1505
  • Fax:
Mailing address:
  • Phone: 941-485-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT37264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: