Provider Demographics
NPI:1386034825
Name:CLUB 50, LLC
Entity Type:Organization
Organization Name:CLUB 50, LLC
Other - Org Name:FYZICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEEFE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FUGLEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-951-0170
Mailing Address - Street 1:1727 2ND ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-8524
Mailing Address - Country:US
Mailing Address - Phone:941-951-0170
Mailing Address - Fax:941-993-1088
Practice Address - Street 1:1727 2ND ST STE 2
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-8524
Practice Address - Country:US
Practice Address - Phone:941-951-0170
Practice Address - Fax:941-993-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL990010114743261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy