MEDICARE: PURSUIT FORT WAYNE LLC

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	:	1275342412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURSUIT FORT WAYNE LLC

Provider Business Mailing Address
First Line	:	4930 ILLINOIS RD STE A1
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4930 ILLINOIS RD STE A1
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5105
Country	:	US
Telephone Number	:	260-240-9596
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RONALD MILLER
Credential	:
Telephone Number	:	407-495-8761

Provider Enumeration Date	:	01/02/2025
Last Update Date	:	01/02/2025

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Directions to “PURSUIT FORT WAYNE LLC ” Practice Location

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