Provider Demographics
NPI:1053505529
Name:OMEGA 40 SPORTS MEDICINE
Entity Type:Organization
Organization Name:OMEGA 40 SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:XYNIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:386-672-4080
Mailing Address - Street 1:1 S OLD KINGS RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6177
Mailing Address - Country:US
Mailing Address - Phone:386-672-4080
Mailing Address - Fax:386-672-6197
Practice Address - Street 1:1 S OLD KINGS RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-6177
Practice Address - Country:US
Practice Address - Phone:386-672-4080
Practice Address - Fax:386-672-6197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0000766261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY2566Medicare PIN