Basic Information
| Provider Information | |||||||||
| NPI: | 1952625162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL INTELLIGENCE ST. AUGUSTINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 MOSES CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046161282 | ||||||||
| FaxNumber: | 9043420642 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 MARINE ST | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320845153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046161282 | ||||||||
| FaxNumber: | 9043420642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | VARELA | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
| AuthorizedOfficialMiddleName: | JOAQUIN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9046161282 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT, PHDC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 18058 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.