=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225010879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELECT THERAPY AND REHABILITATION SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3157 N UNIVERSITY DR SUITE 102
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-2258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-443-3996
-----------------------------------------------------
Fax | 954-443-3994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3157 N UNIVERSITY DR SUITE 102
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-2258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-443-3996
-----------------------------------------------------
Fax | 954-443-3994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. MATTHEW ROBERT WAGGONER
-----------------------------------------------------
Credential | PT, M.S., MTC
-----------------------------------------------------
Telephone | 954-443-3996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | FL 18303
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------