=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457170847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODYFORGE PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2024
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 W FLAGLER ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33135-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-246-5597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5340 SW 59TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-246-5597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID ANTHONY PEREZ-ESPINOSA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 786-246-5597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------