MEDICARE: PHYSICAL THERAPY PROFESSIONALS, 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	:	1639276900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL THERAPY PROFESSIONALS, LLC

Provider Business Mailing Address
First Line	:	8045 SPYGLASS HILL RD
Second Line	:	SUITE 103
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8567
Country	:	US
Telephone Number	:	321-757-5515
Fax Number	:

Provider Business Practice Location Address
First Line	:	8045 SPYGLASS HILL ROAD
Second Line	:	SUITE 103
City	:	MELBOURNE
State	:	FL
Zip	:	32940-7530
Country	:	US
Telephone Number	:	321-757-5515
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/OWNER/MANAGER
Name	:	MR. DARYL CLAYTON JACOBS II
Credential	:	DPT, MTC, ATC
Telephone Number	:	321-591-4369

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/09/2012

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