=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821287574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA PHYSICAL THERAPY SPECIALISTS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12767 TAMIAMI TRL S
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-426-8100
-----------------------------------------------------
Fax | 941-426-0800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 380967
-----------------------------------------------------
City | MURDOCK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33938-0967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-828-3641
-----------------------------------------------------
Fax | 941-830-8370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. OCIEL E BETANCOURT
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 941-426-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PT15536
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT15536
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------