=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417763475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE PT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2024
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 BONAIRE DR
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32413-6006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-353-1305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 BONAIRE DR
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32413-6006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-353-1305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIELLE V MCRAE
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 850-353-1305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------