Basic Information
| Provider Information | |||||||||
| NPI: | 1376597849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6050 BABCOCK ST SE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329093996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216762055 | ||||||||
| FaxNumber: | 3216769928 | ||||||||
| Practice Location | |||||||||
| Address1: | 6050 BABCOCK ST SE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329093996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216762055 | ||||||||
| FaxNumber: | 3216769928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILLS | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3216762055 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 5799 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y3810 | 01 | FL | BCBS | OTHER |