Provider Demographics
NPI:1578562419
Name:SPORTS SPECIALTY & REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:SPORTS SPECIALTY & REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELKE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-573-1518
Mailing Address - Street 1:2328 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1459
Mailing Address - Country:US
Mailing Address - Phone:239-573-1518
Mailing Address - Fax:239-573-7356
Practice Address - Street 1:2328 HANCOCK BRIDGE PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1459
Practice Address - Country:US
Practice Address - Phone:239-574-7557
Practice Address - Fax:239-574-1315
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS SPECIALTY & REHABILITATION CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-20
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68-6520OtherMEDICARE GROUP
FL68-6520OtherMEDICARE GROUP