=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629644935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MOVEMENT CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2021
-----------------------------------------------------
Last Update Date | 05/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3012 E CERVANTES ST
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-6421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-810-4815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 PORTOFINO DR STE 1702
-----------------------------------------------------
City | PENSACOLA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32561-2489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-450-1118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LYNNE VIRANT
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 850-450-1118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------