Provider Demographics
NPI:1336709369
Name:OPTIMAL PERFORMANCE & PHYSICAL THERAPIES WINTER HAVEN, LLC
Entity type:Organization
Organization Name:OPTIMAL PERFORMANCE & PHYSICAL THERAPIES WINTER HAVEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:813-690-4414
Mailing Address - Street 1:21756 STATE ROAD 54 STE 102
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2905
Mailing Address - Country:US
Mailing Address - Phone:727-475-5540
Mailing Address - Fax:
Practice Address - Street 1:5535 CYPRESS GARDENS BLVD STE 260
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-2241
Practice Address - Country:US
Practice Address - Phone:727-475-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-20
Last Update Date:2019-12-24
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
FLPT4616OtherPT LICENSE