=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578878450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIONETICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2010
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1575 PINE RIDGE RD STE 15
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34109-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-593-4348
-----------------------------------------------------
Fax | 239-593-4387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1575 PINE RIDGE RD STE 15
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34109-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-593-4348
-----------------------------------------------------
Fax | 239-593-4387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. NICOLA KHALAF VARVERIS
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 239-593-4348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT10624
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------