Provider Demographics
NPI:1487028874
Name:NEW FORM PHYSICAL THERAPY AND WELLNESS CENTER P.A.
Entity type:Organization
Organization Name:NEW FORM PHYSICAL THERAPY AND WELLNESS CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:SALLES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MSPT, DPT
Authorized Official - Phone:305-766-4181
Mailing Address - Street 1:PO BOX 800625
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33280-0625
Mailing Address - Country:US
Mailing Address - Phone:305-766-4181
Mailing Address - Fax:
Practice Address - Street 1:17971 BISCAYNE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2531
Practice Address - Country:US
Practice Address - Phone:305-999-1844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty