MEDICARE: MR. MARK NILES PT

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	225100000X	Physical Therapist	4421	FL

General Provider Information

NPI Number	:	1093707713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK NILES PT

Provider Business Mailing Address
First Line	:	2180 SW 115TH TER
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33325-4854
Country	:	US
Telephone Number	:	954-816-1029
Fax Number	:	954-577-3444

Provider Business Practice Location Address
First Line	:	2180 SW 115TH TER
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33325-4854
Country	:	US
Telephone Number	:	954-816-1029
Fax Number	:	954-577-3444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	02/05/2008

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Directions to “ MR. MARK NILES PT” Practice Location

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