=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649958471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRU PT AND PERFORMANCE LAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2023
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3183 SW 38TH CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33146-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-574-7517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 331004
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33233-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-574-7517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYLE KRUPA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 570-574-7517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------