Basic Information
| Provider Information | |||||||||
| NPI: | 1215120407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKS | ||||||||
| FirstName: | LYNDA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARNHART | ||||||||
| OtherFirstName: | LYNDA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 129 S PEBBLE BEACH BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335735718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136336800 | ||||||||
| FaxNumber: | 8136336801 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 S PEBBLE BEACH BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335735718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136336800 | ||||||||
| FaxNumber: | 8136336801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P11153 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3400047 | 05 | NC | MEDICAID |