Provider Demographics
NPI:1407492424
Name:SPORTSEDGE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SPORTSEDGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GERNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-451-3008
Mailing Address - Street 1:PO BOX 11147
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339-1147
Mailing Address - Country:US
Mailing Address - Phone:954-451-3002
Mailing Address - Fax:
Practice Address - Street 1:2825 N STATE ROAD 7 STE 204
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5737
Practice Address - Country:US
Practice Address - Phone:954-451-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy