MEDICARE: SELECT PHYSICAL THERAPY

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	174400000X	Specialist	27400	FL

General Provider Information

NPI Number	:	1720323512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELECT PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	3317 US HIGHWAY 98 S STE 6
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-8316
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3317 US HIGHWAY 98 S STE 6
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-8316
Country	:	US
Telephone Number	:	863-667-3092
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	RANDY WIEMER
Credential	:
Telephone Number	:	727-771-7377

Provider Enumeration Date	:	12/05/2012
Last Update Date	:	12/05/2012

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