Basic Information
| Provider Information | |||||||||
| NPI: | 1669583373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIVE STAR PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 236 PONTE VEDRA PARK DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PONTE VEDRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042803440 | ||||||||
| FaxNumber: | 9042803444 | ||||||||
| Practice Location | |||||||||
| Address1: | 236 PONTE VEDRA PARK DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PONTE VEDRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042803440 | ||||||||
| FaxNumber: | 9042803444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SERLO | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9047103730 | ||||||||
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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 | 261QP2000X | FL | X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QR0400X | FL | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.