MEDICARE: PREMIER PHYSICAL THERAPY & SPORTS MEDICINE

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

General Provider Information

NPI Number	:	1205347804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PHYSICAL THERAPY & SPORTS MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 8600
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34985-8600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3660 SW 30TH AVE
Second Line	:
City	:	PALM CITY
State	:	FL
Zip	:	34990-3700
Country	:	US
Telephone Number	:	772-335-7966
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JEFFREY ALAN TUCKER
Credential	:	MPT
Telephone Number	:	772-335-7966

Provider Enumeration Date	:	10/23/2017
Last Update Date	:	02/19/2020

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