Provider Demographics
NPI:1861544603
Name:AVONDALE PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:AVONDALE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:561-346-8508
Mailing Address - Street 1:12471 SAWGRASS CT
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4822
Mailing Address - Country:US
Mailing Address - Phone:451-753-7480
Mailing Address - Fax:561-753-7972
Practice Address - Street 1:12471 SAWGRASS CT
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4822
Practice Address - Country:US
Practice Address - Phone:451-753-7480
Practice Address - Fax:561-753-7972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7125Medicare ID - Type UnspecifiedPHYSICAL THERAPY