=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861288870
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYLES LUSTER PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2025
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1826 N CRYSTAL LAKE DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33801-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-876-8771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1826 N CRYSTAL LAKE DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33801-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-876-8771
-----------------------------------------------------
Fax | 813-333-5414
-----------------------------------------------------
=====================================================
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 | 33993
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------