=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568025385
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRITTEN HARDEN PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2019
-----------------------------------------------------
Last Update Date | 04/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1706 E SEMORAN BLVD STE 107
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32703-5610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-880-7772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11415 CITRA CIR APT 7-303
-----------------------------------------------------
City | WINDERMERE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34786-5957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-209-4335
-----------------------------------------------------
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 | 29270
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------