Provider Demographics
NPI:1134481005
Name:ADVANCED WELLNESS & SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:ADVANCED WELLNESS & SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-875-2460
Mailing Address - Street 1:14028 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-4311
Mailing Address - Country:US
Mailing Address - Phone:352-600-2232
Mailing Address - Fax:352-292-0136
Practice Address - Street 1:14028 5TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525
Practice Address - Country:US
Practice Address - Phone:352-600-2232
Practice Address - Fax:352-292-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10458111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty