MEDICARE: XL PHYSICAL THERAPY AND SPORTS REHAB

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	PT16359	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT16359	OTHER	FL	FLORIDA STATE LICENSE

General Provider Information

NPI Number	:	1346646148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	XL PHYSICAL THERAPY AND SPORTS REHAB

Provider Business Mailing Address
First Line	:	2001 NE 48TH ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-4517
Country	:	US
Telephone Number	:	954-347-2151
Fax Number	:	954-566-2409

Provider Business Practice Location Address
First Line	:	2001 NE 48TH ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-4517
Country	:	US
Telephone Number	:	954-347-2151
Fax Number	:	954-566-2409

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MR. JACK C ZATORSKI JR.
Credential	:	PT
Telephone Number	:	954-347-2151

Provider Enumeration Date	:	11/06/2014
Last Update Date	:	11/06/2014

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