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General NPI Number Information
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NPI Number | 1134292253
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Entity Type | Organization
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Legal Business Name | MAINSTREAM PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9371 CYPRESS LAKE DR SUITE 20
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City | FORT MYERS
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State | FL
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Zip | 33919-4939
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Country | US
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Telephone | 239-415-2595
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Fax | 239-415-2597
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Provider Business Mailing Address
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Address Line | 9371 CYPRESS LAKE DR SUITE 20
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City | FORT MYERS
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State | FL
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Zip | 33919-4939
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Country | US
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Telephone | 239-415-2595
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Fax | 239-415-2597
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | MR. RUSSELL WADE STEPHAN
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Credential | MSM MPT
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Telephone | 239-415-2595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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