=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700562683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ALEX PESKOE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2023
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17842 NW 2ND ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-430-9901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11409 SW 45TH CT 14-111
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-232-3747
-----------------------------------------------------
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 | 32650
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------