Basic Information
| Provider Information | |||||||||
| NPI: | 1013088962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE B-2 | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321748130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868980443 | ||||||||
| FaxNumber: | 3868980459 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE B-2 | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321748130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868980443 | ||||||||
| FaxNumber: | 3868980459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 01/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | PIAZZA | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3868980443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DPT, ATC, MTC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | HCC5366 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 6457550001 | 01 | FL | PTAN | OTHER |