=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194066415
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELMER BRIGNONI DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2013
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 854 S DUNCAN DR
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-4044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-205-6147
-----------------------------------------------------
Fax | 352-306-0571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 RIVIERA DR
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-6741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-205-6147
-----------------------------------------------------
Fax | 352-306-0571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT27229
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT27229
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------