=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508526260
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGENE BRUCE PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2021
-----------------------------------------------------
Last Update Date | 12/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10685 SW STONY CREEK WAY
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-2741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-252-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 394 SW DALTON CIR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-5848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-204-2821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 21496
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------