1730397076 NPI number — PHYSICAL & SPORTS THERAPY CENTER, INC

Table of content: (NPI 1730397076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730397076 NPI number — PHYSICAL & SPORTS THERAPY CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL & SPORTS THERAPY CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHYSICAL & SPORTS THERAPY CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730397076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7480 FAIRWAY DR
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
MIAMI LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33014-6879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-824-9292
Provider Business Mailing Address Fax Number:
305-824-0033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7480 FAIRWAY DR
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33014-6879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-824-9292
Provider Business Practice Location Address Fax Number:
305-824-0033
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMEDES
Authorized Official First Name:
NIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
305-824-9292

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  PT2508 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y915N . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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