MEDICARE: NETHERINE S PHYSICAL THERAPY PELVIC FLOOR AND WELLNESS P C

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	:	1326742669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NETHERINE S PHYSICAL THERAPY PELVIC FLOOR AND WELLNESS P C

Provider Business Mailing Address
First Line	:	1236 W COLLEGE AVE
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2215
Country	:	US
Telephone Number	:	217-248-9355
Fax Number	:	217-248-9355

Provider Business Practice Location Address
First Line	:	1236 W COLLEGE AVE
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2215
Country	:	US
Telephone Number	:	217-248-9355
Fax Number	:	217-248-9355

Authorized Official
Title or Position	:	OWNER
Name	:	NETHERINE LANN AGSALDA
Credential	:	PT, DPT, CMTPT
Telephone Number	:	217-248-9355

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	03/29/2023

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Directions to “NETHERINE S PHYSICAL THERAPY PELVIC FLOOR AND WELLNESS P C ” Practice Location

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