Basic Information
| Provider Information | |||||||||
| NPI: | 1720147226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOB | ||||||||
| FirstName: | TRISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAMPBELL | ||||||||
| OtherFirstName: | TRISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 35902 HWY 27 | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338443737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634211777 | ||||||||
| FaxNumber: | 8634217070 | ||||||||
| Practice Location | |||||||||
| Address1: | 35902 HWY 27 | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338443737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634211777 | ||||||||
| FaxNumber: | 8634217070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 32381 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 028431 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.