Provider Demographics
NPI:1285104828
Name:PEACE RIVER PHYSICAL THERAPY & REHABILITATION, LLC
Entity type:Organization
Organization Name:PEACE RIVER PHYSICAL THERAPY & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOEBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:941-888-4561
Mailing Address - Street 1:PO BOX 510326
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-0326
Mailing Address - Country:US
Mailing Address - Phone:941-888-4561
Mailing Address - Fax:
Practice Address - Street 1:2200 KINGS HWY UNIT 2F
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-5760
Practice Address - Country:US
Practice Address - Phone:941-888-4561
Practice Address - Fax:941-347-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty