Provider Demographics
NPI:1801203674
Name:NIRVANA SPORTS MEDICINE AND REHABILITATION SERVICES, LLC.
Entity Type:Organization
Organization Name:NIRVANA SPORTS MEDICINE AND REHABILITATION SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MITCHELL-VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-647-5008
Mailing Address - Street 1:1890 W COUNTY ROAD 419
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-4402
Mailing Address - Country:US
Mailing Address - Phone:407-647-5008
Mailing Address - Fax:407-374-1683
Practice Address - Street 1:1890 W COUNTY ROAD 419
Practice Address - Street 2:SUITE 1000
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-4402
Practice Address - Country:US
Practice Address - Phone:407-647-5008
Practice Address - Fax:407-374-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy