=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427429604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIOFIX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2015
-----------------------------------------------------
Last Update Date | 10/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3355 COPTER RD BLDG 1&2
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32514-7083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-529-3496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3155 SONYA ST
-----------------------------------------------------
City | PACE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32571-9554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-529-3496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | KERRILYN GAVIN
-----------------------------------------------------
Credential | PT, DPT, MTC
-----------------------------------------------------
Telephone | 850-529-3496
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------