Provider Demographics
NPI:1386205599
Name:SPORTS AND ORTHOPEDIC CENTER PA
Entity Type:Organization
Organization Name:SPORTS AND ORTHOPEDIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-481-9942
Mailing Address - Street 1:6280 W SAMPLE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3173
Mailing Address - Country:US
Mailing Address - Phone:954-481-9942
Mailing Address - Fax:954-481-9917
Practice Address - Street 1:7545 W BOYNTON BEACH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-6167
Practice Address - Country:US
Practice Address - Phone:954-481-9942
Practice Address - Fax:954-481-9917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty