=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164962619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OWENS MANAGEMENT COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2017
-----------------------------------------------------
Last Update Date | 03/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3322 SAWTOOTH DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32303-7368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-570-3036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3322 SAWTOOTH DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32303-7368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-493-1195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | TRISTAN OWENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-493-1195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------