Provider Demographics
NPI:1386618064
Name:PHYSICAL THERAPY & REHABILITATION CLINIC INC
Entity type:Organization
Organization Name:PHYSICAL THERAPY & REHABILITATION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WELDON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:904-272-2830
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-272-2830
Mailing Address - Fax:904-272-8814
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-272-2830
Practice Address - Fax:904-272-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022381500Medicaid
FL022381502Medicaid
FL022381503Medicaid