Provider Demographics
NPI:1871670778
Name:ADVANCED CLINICAL & ORTHOPEDIC MASSAGE INC
Entity Type:Organization
Organization Name:ADVANCED CLINICAL & ORTHOPEDIC MASSAGE INC
Other - Org Name:THE INJURY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, NCMMT
Authorized Official - Phone:561-684-1169
Mailing Address - Street 1:537 GOLDENWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4966
Mailing Address - Country:US
Mailing Address - Phone:561-798-3564
Mailing Address - Fax:561-798-3564
Practice Address - Street 1:2930 OKEECHOBEE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-4037
Practice Address - Country:US
Practice Address - Phone:561-684-1169
Practice Address - Fax:561-684-6112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC4052OtherBCBS OF FLORIDA ID #