| Organization Name: | PROVIDIAN FUNCTIONAL CAPACITY SPECIALISTS |
| NPI Number: | 1013258862 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BRIAN SCOTT IMLER (PRESIDENT) |
| Mailing Address: | 716 N Orange Ave Green Cove Springs |
| State: | FL US |
| Postal Code: | 320432920 |
| Phone Number: | 8889573337 |
| Fax Number: | 9042844244 |
| NPI Enumeration Date: | 03/04/2013 |
| NPI Last Update Date: | 03/04/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2000X |
| License Number: | AL1714 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Physical Therapy |
| Taxonomy Definition: | |