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General NPI Number Information
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NPI Number | 1750580460
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Entity Type | Organization
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Legal Business Name | SPINAL THERAPY MEDICAL GROUP FL
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Dates
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Enumeration Date | 07/12/2007
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Last Update Date | 07/23/2007
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Provider Practice Location Address
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Address Line | 433 PLAZA REAL SUITE 255
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City | BOCA RATON
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State | FL
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Zip | 33432-3932
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Country | US
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Telephone | 561-237-1717
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Fax | 561-237-1725
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Provider Business Mailing Address
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Address Line | 433 PLAZA REAL SUITE 255
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City | BOCA RATON
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State | FL
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Zip | 33432-3932
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Country | US
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Telephone | 561-237-1717
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Fax | 561-237-1725
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Authorized Official
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Title or Position | PRESIDENT
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Name | LORI WEISER
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Credential | PTA
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Telephone | 561-237-1717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME51866
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PTA17624
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License Number State | FL
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