=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104897768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTH DENCH PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 1ST ST S SUITE 202
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-3665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-7778
-----------------------------------------------------
Fax | 863-299-3836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16413 BRIDGELAWN AVE
-----------------------------------------------------
City | LITHIA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33547-4849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-829-9009
-----------------------------------------------------
Fax | 863-299-3836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA00724500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------