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General NPI Number Information
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NPI Number | 1487028874
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Entity Type | Organization
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Legal Business Name | NEW FORM PHYSICAL THERAPY AND WELLNESS CENTER P.A.
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Dates
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Enumeration Date | 11/23/2015
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Last Update Date | 09/01/2023
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Provider Practice Location Address
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Address Line | 17971 BISCAYNE BLVD STE 104
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City | AVENTURA
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State | FL
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Zip | 33160-2531
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Country | US
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Telephone | 305-999-1844
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 800625
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City | AVENTURA
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State | FL
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Zip | 33280-0625
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Country | US
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Telephone | 305-766-4181
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MRS. SIMONE SALLES
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Credential | PT, MSPT, DPT
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Telephone | 305-766-4181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT23183
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License Number State | FL
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