Provider Demographics
NPI:1659697480
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:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:VOGELBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
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 1:4316 LEE BLVD
Practice Address - Street 2:SUITE 12A & 12B
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1735
Practice Address - Country:US
Practice Address - Phone:239-368-7744
Practice Address - Fax:239-368-7824
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS SPECIALTY & REHABILITATION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-19
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6646225100000X, 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
FL6366480003Medicare NSC
FL686520Medicare PIN