=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184139115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER MATTHEW NINAN DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2017
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 E COUNTY ROAD 540A
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-607-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 APACHE LN
-----------------------------------------------------
City | SEFFNER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33584-4749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-995-1569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PT37527
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AL4398
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------