Basic Information
| Provider Information | |||||||||
| NPI: | 1346505559 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICAL THERAPY AT HOME INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 MAY APPLE WAY | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342937278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412065200 | ||||||||
| FaxNumber: | 9415046842 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 JACARANDA BLVD | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342924586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412065200 | ||||||||
| FaxNumber: | 9415046842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2012 | ||||||||
| LastUpdateDate: | 10/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | IBRAHIM ALI | ||||||||
| AuthorizedOfficialFirstName: | GOMAA | ||||||||
| AuthorizedOfficialMiddleName: | RAMADAM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9412065200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT12658 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.