Provider Demographics
NPI:1487081345
Name:PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Entity type:Organization
Organization Name:PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELDON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
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:32073-5144
Mailing Address - Country:US
Mailing Address - Phone:904-272-2830
Mailing Address - Fax:904-272-8814
Practice Address - Street 1:2520 COMMERCIAL DR STE C
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-7860
Practice Address - Country:US
Practice Address - Phone:904-386-1257
Practice Address - Fax:904-368-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106524Medicare UPIN