=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508817537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIOTHERAPY PLUS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2006
-----------------------------------------------------
Last Update Date | 01/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6388 SILVER STAR RD STE 1E
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-369-9133
-----------------------------------------------------
Fax | 888-696-1020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6388 SILVER STAR RD 1E
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-369-9133
-----------------------------------------------------
Fax | 888-696-1020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIR
-----------------------------------------------------
Name | IDLER BONHOMME
-----------------------------------------------------
Credential | LMT, MPT, DPT
-----------------------------------------------------
Telephone | 321-369-9133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA 32752
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 21887
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------