Healthcare Provider Details

I. General information

NPI: 1336709369
Provider Name (Legal Business Name): OPTIMAL PERFORMANCE & PHYSICAL THERAPIES WINTER HAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 CYPRESS GARDENS BLVD STE 260
WINTER HAVEN FL
33884-2241
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: 727-475-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BETH PATTERSON
Title or Position: CHIEF COMPLIANCE OFFICER/OWNER
Credential: PT
Phone: 813-690-4414