=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679921183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL APPROACH REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2016
-----------------------------------------------------
Last Update Date | 05/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 ANCHOR WAY
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34946-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-979-4630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 351 ANCHOR WAY
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34946-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-979-4630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED MEMBER/DPT
-----------------------------------------------------
Name | DR. MODESTINO TOMASSI
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 772-979-4630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT28490
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------