MEDICARE: PONTE VEDRA PHYSICAL THERAPY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R9F	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1043246580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONTE VEDRA PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 48116
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32247-8116
Country	:	US
Telephone Number	:	904-725-1657
Fax Number	:	904-725-7247

Provider Business Practice Location Address
First Line	:	880 A1A N
Second Line	:	SUITE 18A
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-3221
Country	:	US
Telephone Number	:	904-285-2910
Fax Number	:	904-285-4663

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JEFFREY C PARKS
Credential	:
Telephone Number	:	904-285-2910

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	12/07/2007

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Directions to “PONTE VEDRA PHYSICAL THERAPY, INC. ” Practice Location

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