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Organization
PREMIER PHYSICAL THERAPY SPORT MEDICINE INC
Active
Organization
PREMIER PHYSICAL THERAPY SPORT MEDICINE INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY ALAN TUCKER MPT (EXECUTIVE DIRECTOR)
(772) 335-7966
Entity
Organization
Contact information
Practice address
519 NW LAKE WHITNEY PL, SUITE 101, PORT ST LUCIE, FL 34986-1621
(772) 621-9313
(772) 621-9358
Mailing address
PO BOX 8600, PORT ST LUCIE, FL 34985
(772) 335-7966
(772) 335-7963
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
650023083
RAILROAD MEDICARE
FL
01
—
CK5189
RAILROAD MEDICARE PTAN
FL
01
—
Y905B
BCBS PROVIDER NUMBER
FL
Enumeration date
08/30/2006
Last updated
02/19/2020
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