Provider Demographics
NPI:1063910982
Name:POTENTIA THERAPEUTICS, LLC
Entity type:Organization
Organization Name:POTENTIA THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-374-9508
Mailing Address - Street 1:2307 S DALE MABRY HWY STE F
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2307 S DALE MABRY HWY STE F
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6322
Practice Address - Country:US
Practice Address - Phone:813-374-9508
Practice Address - Fax:813-443-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty