1437277308 NPI number — ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER LLC

Table of content: (NPI 1437277308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437277308 NPI number — ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER 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:
1437277308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 BLUEWATER BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-3887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-897-3334
Provider Business Mailing Address Fax Number:
850-897-7855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7552 NAVARRE PKWY
Provider Second Line Business Practice Location Address:
SUITE 32
Provider Business Practice Location Address City Name:
NAVARRE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32566-7305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-939-4913
Provider Business Practice Location Address Fax Number:
850-939-4915
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPPARD
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
850-897-3334

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8913153 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING . This is a "BCBS GRP # PENDING" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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