Provider Demographics
NPI:1134320914
Name:SPORTS MED INNOVATIONS INC
Entity Type:Organization
Organization Name:SPORTS MED INNOVATIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-234-7788
Mailing Address - Street 1:717 PONCE DE LEON BLVD
Mailing Address - Street 2:STE 221
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2060
Mailing Address - Country:US
Mailing Address - Phone:305-234-7788
Mailing Address - Fax:305-969-9274
Practice Address - Street 1:717 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 221
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2060
Practice Address - Country:US
Practice Address - Phone:305-234-7788
Practice Address - Fax:305-969-9274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FL6047450001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6047450001Medicare NSC