=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548291552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTJAN FRIDRIKSSON PHYSICAL THERAPY SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 GRELOT RD BUILDING B, SUITE B
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36609-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-343-1178
-----------------------------------------------------
Fax | 251-343-1741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5901 GRELOT RD BUILDING B, SUITE B
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-343-1178
-----------------------------------------------------
Fax | 251-343-1741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. KRISTJAN INGI FRIDRIKSSON
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 251-343-1178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PTH3558
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------