Provider Demographics
NPI:1245411438
Name:SPORTS MEDICINE AND REHABILITATION THERAPY
Entity Type:Organization
Organization Name:SPORTS MEDICINE AND REHABILITATION THERAPY
Other - Org Name:SMART PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-691-3665
Mailing Address - Street 1:1983 PGA BLVD
Mailing Address - Street 2:SUITE# 105-B
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-3001
Mailing Address - Country:US
Mailing Address - Phone:561-691-3665
Mailing Address - Fax:561-691-3668
Practice Address - Street 1:1983 PGA BLVD
Practice Address - Street 2:SUITE# 105-B
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-3001
Practice Address - Country:US
Practice Address - Phone:561-691-3665
Practice Address - Fax:561-691-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4947Medicare PIN