=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912246737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANE SIWEK PT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2013
-----------------------------------------------------
Last Update Date | 02/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5299 PARK PLACE CIR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33486-1462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-573-5955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5299 PARK PLACE CIR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33486-1462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-573-5955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. DIANE SIWEK
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 561-573-5955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | PT0001921
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------