Provider Demographics
NPI:1326854159
Name:TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
Entity type:Organization
Organization Name:TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:C
Authorized Official - Last Name:KNISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:850-545-5318
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1431 OHIO AVE N
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4817
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:2024-12-06
Last Update Date:2024-12-06
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid