Provider Demographics
NPI:1629350137
Name:SPORT AND SPINE PHYSICAL THERAPY AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SPORT AND SPINE PHYSICAL THERAPY AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, DPT
Authorized Official - Phone:813-948-1020
Mailing Address - Street 1:17824 N US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4502
Mailing Address - Country:US
Mailing Address - Phone:813-948-1020
Mailing Address - Fax:813-948-1022
Practice Address - Street 1:17824 N US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549
Practice Address - Country:US
Practice Address - Phone:813-948-1020
Practice Address - Fax:813-948-1022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22249261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL169-9988006OtherINDIVIDUAL NPI
FL12098575OtherCAQH
FLCZ108AOtherPTAN