=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366994519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHI-THERAS REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2016
-----------------------------------------------------
Last Update Date | 11/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12450 TAMIAMI TRL S SUITE E
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-257-4763
-----------------------------------------------------
Fax | 941-257-4766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12450 TAMIAMI TRL S SUITE E
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-257-4763
-----------------------------------------------------
Fax | 941-257-4766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JORDAN SERRANO
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 941-257-4763
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | PT29353
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | PT29353
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------