Provider Demographics
NPI:1104956341
Name:TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
Entity type:Organization
Organization Name:TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:KNISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:850-973-3316
Mailing Address - Street 1:PO BOX 13269
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-3269
Mailing Address - Country:US
Mailing Address - Phone:850-219-1520
Mailing Address - Fax:850-219-1521
Practice Address - Street 1:257 SW DADE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2361
Practice Address - Country:US
Practice Address - Phone:850-973-3316
Practice Address - Fax:850-973-1261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883224200OtherPARENT FACILITY MEDICAID ID
FL883224205Medicaid
FL1376593053OtherPARENT FACILITY NPI
FL106822Medicare ID - Type Unspecified