Provider Demographics
NPI:1063805042
Name:PROTAILORED PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PROTAILORED PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:260-570-8239
Mailing Address - Street 1:12722 TONKEL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8201
Mailing Address - Country:US
Mailing Address - Phone:260-739-0300
Mailing Address - Fax:260-818-2299
Practice Address - Street 1:12722 TONKEL RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8201
Practice Address - Country:US
Practice Address - Phone:260-739-0300
Practice Address - Fax:260-818-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-14
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011654A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201289250AMedicaid