Basic Information
| Provider Information | |||||||||
| NPI: | 1902004609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMES | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | AMES | ||||||||
| OtherFirstName: | JIM | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 660 E EAU GALLIE BLVD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217735290 | ||||||||
| FaxNumber: | 3217735268 | ||||||||
| Practice Location | |||||||||
| Address1: | 4270 MINTON RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329049578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216906612 | ||||||||
| FaxNumber: | 3216902630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 06/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 2171 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT2171 | 01 | FL | PT LICENSE | OTHER |