=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104276724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN TALBOTT P.T., A.T.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2016
-----------------------------------------------------
Last Update Date | 06/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 E ALTAMONTE DR STE 200
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-5465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 E ALTAMONTE DR STE 200
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-5465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT22988
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------