Provider Demographics
NPI:1770660474
Name:THERAPEUTIC AND SPORTS MASSAGE INC
Entity Type:Organization
Organization Name:THERAPEUTIC AND SPORTS MASSAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:954-776-1902
Mailing Address - Street 1:2821 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4216
Mailing Address - Country:US
Mailing Address - Phone:954-776-1902
Mailing Address - Fax:954-776-9130
Practice Address - Street 1:2821 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4216
Practice Address - Country:US
Practice Address - Phone:954-776-1902
Practice Address - Fax:954-776-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA5866225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC5493OtherBLUECROSS BLUESHIELD