=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265250781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIOTHERAPY WORKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4824 GRANDVIEW PKWY
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-808-1888
-----------------------------------------------------
Fax | 863-808-1888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4605
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32793-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-657-5029
-----------------------------------------------------
Fax | 407-657-6320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ERIC S MASON
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 407-657-5029
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------