=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538199435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MEDICAL THERAPY INSTITUTE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 06/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6776 54TH AVE N SUITE B
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33709-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-397-9118
-----------------------------------------------------
Fax | 727-397-9440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6776 54TH AVE N SUITE B
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33709-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-397-9118
-----------------------------------------------------
Fax | 727-397-9440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOE DISTEFANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-397-9118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------