=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326098690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD ROBERTS PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 08/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 TOWN CT
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32164-2589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-313-5974
-----------------------------------------------------
Fax | 866-647-2045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1975
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30162-1975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-236-2755
-----------------------------------------------------
Fax | 866-647-2045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT007632
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT19497
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------