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General NPI Number Information
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NPI Number | 1215536776
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Entity Type | Organization
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Legal Business Name | OPTIMIZE PHYSICAL THERAPY AND SPORTS PERFORMANCE, LLC
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Dates
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Enumeration Date | 10/25/2020
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Last Update Date | 10/25/2020
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Provider Practice Location Address
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Address Line | 3030 POWERS AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8043
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Country | US
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Telephone | 219-805-1184
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Fax |
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Provider Business Mailing Address
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Address Line | 4941 WHITE BLUFF DR
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City | JACKSONVILLE
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State | FL
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Zip | 32225-1115
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Country | US
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Telephone | 219-805-1184
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN JACOB EVANICH
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Credential | PT, DPT, OCS
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Telephone | 219-805-1184
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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