Provider Demographics
NPI:1598004053
Name:GE SPINE ORTHOPEDIC SPORTS THERAPY CENTER LLC
Entity Type:Organization
Organization Name:GE SPINE ORTHOPEDIC SPORTS THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:COMSON
Authorized Official - Last Name:PENANO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:941-268-5577
Mailing Address - Street 1:7331 COLLEGE PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5524
Mailing Address - Country:US
Mailing Address - Phone:941-268-5577
Mailing Address - Fax:
Practice Address - Street 1:7331 COLLEGE PKWY STE 230
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5524
Practice Address - Country:US
Practice Address - Phone:941-268-5577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0007217261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT0007217OtherFL PT