=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740374073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLK REHABILITATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1326 STATE ROAD 60 E STE 200
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-679-3545
-----------------------------------------------------
Fax | 863-679-3924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1326 STATE ROAD 60 E STE 200
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-679-3545
-----------------------------------------------------
Fax | 863-679-3924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | MR. PETER G KALOGRIDIS
-----------------------------------------------------
Credential | M.P.T.
-----------------------------------------------------
Telephone | 863-679-3545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number | PT14814
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------