MEDICARE: MAXWELLNESS PHYSICAL THERAPY 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	261QP2000X	Physical Therapy Clinic/Center	PT20304	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT20304	OTHER	FL	MEDICAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881083475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXWELLNESS PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	18600 NW 87TH AVE UNIT 126
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-3536
Country	:	US
Telephone Number	:	954-869-4310
Fax Number	:	954-869-4313

Provider Business Practice Location Address
First Line	:	18600 NW 87TH AVE UNIT 126
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-3536
Country	:	US
Telephone Number	:	954-869-4310
Fax Number	:	954-869-4313

Authorized Official
Title or Position	:	PHYSICAL THERAPY DIRECTOR
Name	:	MR. JEAN PASCAL PRADEL
Credential	:	PT
Telephone Number	:	954-558-3462

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	07/20/2020

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