=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528685666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY LIFESTYLE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2020
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 E HILLSBORO BLVD STE 104
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33441-3628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-642-8865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 E HILLSBORO BLVD STE 104
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33441-3628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-642-8865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DMITRY RUTENBERG
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 917-642-8865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------