Provider Demographics
NPI:1013557826
Name:SPORTZ REHAB LLC
Entity Type:Organization
Organization Name:SPORTZ REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DIOGO
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVISAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:786-286-4119
Mailing Address - Street 1:9767 SW 72ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4615
Mailing Address - Country:US
Mailing Address - Phone:305-570-1666
Mailing Address - Fax:305-203-0546
Practice Address - Street 1:9767 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-4615
Practice Address - Country:US
Practice Address - Phone:305-570-1666
Practice Address - Fax:305-203-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT31195OtherMEDICAL LICENSE