Provider Demographics
NPI:1316970114
Name:WHORTON, ROBERT LANCE (PT, MS, MTC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LANCE
Last Name:WHORTON
Suffix:
Gender:M
Credentials:PT, MS, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3737
Mailing Address - Country:US
Mailing Address - Phone:850-226-6801
Mailing Address - Fax:877-413-5104
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3737
Practice Address - Country:US
Practice Address - Phone:850-226-6801
Practice Address - Fax:877-413-5104
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006780225100000X
FLPT29006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ33264Medicare UPIN