=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003408196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WADDIE FREEMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2021
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 W REYNOLDS ST STE 101
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-3377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-261-0130
-----------------------------------------------------
Fax | 813-261-0603
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 W REYNOLDS ST STE 104
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-3377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-370-7817
-----------------------------------------------------
Fax | 813-261-0603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA2368
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------