Provider Demographics
NPI:1578143426
Name:SPORTS & LIFESTYLE CLINIC, INC.
Entity Type:Organization
Organization Name:SPORTS & LIFESTYLE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-297-3089
Mailing Address - Street 1:7600 RED ROAD
Mailing Address - Street 2:STE. #333
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143
Mailing Address - Country:US
Mailing Address - Phone:954-297-3089
Mailing Address - Fax:
Practice Address - Street 1:7600 RED ROAD
Practice Address - Street 2:STE. #333
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143
Practice Address - Country:US
Practice Address - Phone:954-297-3089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty