Provider Demographics
NPI:1134532054
Name:SPINAL HEALTH AND REHAB OF PUNTA GORDA, INC.
Entity type:Organization
Organization Name:SPINAL HEALTH AND REHAB OF PUNTA GORDA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN NOSTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-258-1965
Mailing Address - Street 1:324 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-4828
Mailing Address - Country:US
Mailing Address - Phone:941-205-2180
Mailing Address - Fax:941-205-2181
Practice Address - Street 1:324 CROSS ST
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4828
Practice Address - Country:US
Practice Address - Phone:941-205-2180
Practice Address - Fax:941-205-2181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINAL HEALTH AND REHAB OF PUNTA GORDA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 18108225100000X
FLME 1029972081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty