Provider Demographics
NPI:1003903261
Name:LEADING EDGE PHYSICAL THERAPY & SPORTS, INC.
Entity Type:Organization
Organization Name:LEADING EDGE PHYSICAL THERAPY & SPORTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:T
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:863-688-1800
Mailing Address - Street 1:500 S FLORIDA AVE STE 16
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5276
Mailing Address - Country:US
Mailing Address - Phone:863-688-1800
Mailing Address - Fax:863-688-1824
Practice Address - Street 1:500 S FLORIDA AVE STE 620
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5269
Practice Address - Country:US
Practice Address - Phone:863-688-1800
Practice Address - Fax:863-688-1824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686545Medicare Oscar/Certification