=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922607845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNDAMENTAL THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2020
-----------------------------------------------------
Last Update Date | 10/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4106 N 48TH AVE
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-648-7819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4106 N 48TH AVE
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-648-7819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANNIEL NAGLER
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 954-648-7819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------