Provider Demographics
NPI:1548262488
Name:FLORIDA PHYSICAL THERAPY SPECIALISTS PORT CHARLOTTE INC.
Entity type:Organization
Organization Name:FLORIDA PHYSICAL THERAPY SPECIALISTS PORT CHARLOTTE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:VALDIVIA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-468-1660
Mailing Address - Street 1:PO BOX 1551
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284-1551
Mailing Address - Country:US
Mailing Address - Phone:941-468-1660
Mailing Address - Fax:941-484-6024
Practice Address - Street 1:24430 SANDHILL BLVD UNIT 301
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5216
Practice Address - Country:US
Practice Address - Phone:941-625-2907
Practice Address - Fax:941-766-1631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY053NOtherBCBS
001872584OtherHIGHMARK BCBS
FLK7347Medicare ID - Type UnspecifiedGROUP NUMBER
FLY053NOtherBCBS
FLDE3452Medicare ID - Type UnspecifiedRR MEDICARE GROUP #