Provider Demographics
NPI:1104893361
Name:BONITA SPRINGS SPORTS & PHYSICAL THERAPY CENTER INC
Entity type:Organization
Organization Name:BONITA SPRINGS SPORTS & PHYSICAL THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KLASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT AT C
Authorized Official - Phone:239-498-0558
Mailing Address - Street 1:26201 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134
Mailing Address - Country:US
Mailing Address - Phone:239-498-0558
Mailing Address - Fax:239-498-0557
Practice Address - Street 1:26201 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134
Practice Address - Country:US
Practice Address - Phone:239-498-0558
Practice Address - Fax:239-498-0557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y905QOtherBCBS
Y905QOtherBCBS