=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073811865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AQUAMED CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2011
-----------------------------------------------------
Last Update Date | 03/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 S CONGRESS AVE
-----------------------------------------------------
City | ATLANTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33462-1347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-965-2126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5841 S CONGRESS AVE
-----------------------------------------------------
City | ATLANTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33462-1347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THERESA PANTANELLA
-----------------------------------------------------
Credential | D.O.T.
-----------------------------------------------------
Telephone | 561-965-2126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 26014
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------