=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215114665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN KEITH PITTS L.M.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2008
-----------------------------------------------------
Last Update Date | 01/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2629 W 23RD ST STE E
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-814-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2629 WEST 23RD. ST. SUITE E.
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-814-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | MA51160
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------