Provider Demographics
NPI:1851022933
Name:HOUSE OF ATHLETE TAMPA LLC
Entity Type:Organization
Organization Name:HOUSE OF ATHLETE TAMPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:813-601-9036
Mailing Address - Street 1:6912 ASPHALT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3625
Mailing Address - Country:US
Mailing Address - Phone:262-488-0118
Mailing Address - Fax:
Practice Address - Street 1:6912 ASPHALT AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3625
Practice Address - Country:US
Practice Address - Phone:262-488-0118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty