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General NPI Number Information
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NPI Number | 1871694919
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Entity Type | Organization
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Legal Business Name | PERFORMANCE PHYSICAL THERAPY INC
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 01/15/2009
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Provider Practice Location Address
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Address Line | 150 SOUTHPARK BLVD SUITE 201
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5190
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Country | US
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Telephone | 904-824-7787
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Fax | 904-429-0318
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Provider Business Mailing Address
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Address Line | 150 SOUTHPARK BLVD SUITE 201
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5190
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Country | US
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Telephone | 904-824-7787
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Fax | 904-429-0318
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Authorized Official
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Title or Position | C.E.O.
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Name | MS. KAREN L HASELTINE
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Credential |
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Telephone | 904-824-7787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT21013
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License Number State | FL
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