=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336873777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROACTIVE PHYSICAL THERAPY OF FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2022
-----------------------------------------------------
Last Update Date | 07/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5660 GULF BREEZE PKWY UNIT A-1
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32563-9599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-607-3546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 FORT PICKENS RD APT 2F
-----------------------------------------------------
City | PENSACOLA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32561-2043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-607-3546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MICHAEL SCOTT DEMAHY
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 850-698-0438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------