1407492424 NPI number — SPORTSEDGE PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407492424 NPI number — SPORTSEDGE PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTSEDGE PHYSICAL THERAPY, LLC
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:
Provider Other Organization Name Type Code:
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:
1407492424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33339-1147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-451-3002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 N STATE ROAD 7 STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARGATE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33063-5737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-451-3002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
GERNELL
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
954-451-3008

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com