=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437207644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPY FOR HEALTHY LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2007
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19233 NW 13TH ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-4510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-651-5773
-----------------------------------------------------
Fax | 954-538-1973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19233 NW 13TH ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-4510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-651-5773
-----------------------------------------------------
Fax | 954-538-1973
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. MARIA SOCORRO CASIMIRO JANDAYAN
-----------------------------------------------------
Credential | RPT
-----------------------------------------------------
Telephone | 954-651-5773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT11478
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------