Provider Demographics
NPI:1912191859
Name:SPORTS SPINE OCCUPATIONAL REHABILITATION INC
Entity Type:Organization
Organization Name:SPORTS SPINE OCCUPATIONAL REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARRASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-852-8636
Mailing Address - Street 1:10637 MENDOCINO LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1229
Mailing Address - Country:US
Mailing Address - Phone:561-852-8636
Mailing Address - Fax:561-852-8672
Practice Address - Street 1:9945 CENTRAL PARK BLVD N
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1745
Practice Address - Country:US
Practice Address - Phone:561-483-0498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5659Medicare PIN