MEDICARE: OPTIMAL PERFORMANCE & PHYSICAL THERAPIES WINTER HAVEN, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT4616	OTHER	FL	PT LICENSE

General Provider Information

NPI Number	:	1336709369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL PERFORMANCE & PHYSICAL THERAPIES WINTER HAVEN, LLC

Provider Business Mailing Address
First Line	:	21756 STATE ROAD 54 STE 102
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33549-2905
Country	:	US
Telephone Number	:	727-475-5540
Fax Number	:

Provider Business Practice Location Address
First Line	:	5535 CYPRESS GARDENS BLVD STE 260
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-2241
Country	:	US
Telephone Number	:	727-475-5540
Fax Number	:

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER/OWNER
Name	:	BETH PATTERSON
Credential	:	PT
Telephone Number	:	813-690-4414

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	12/24/2019

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