Provider Demographics
NPI:1255930855
Name:TIDELINE SPORTS PERFORMANCE & REHABILITATION LLC
Entity type:Organization
Organization Name:TIDELINE SPORTS PERFORMANCE & REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCLAFANI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:941-218-0551
Mailing Address - Street 1:5320 LENA RD UNIT 114
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-9438
Mailing Address - Country:US
Mailing Address - Phone:513-460-8005
Mailing Address - Fax:
Practice Address - Street 1:5320 LENA RD UNIT 114
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9438
Practice Address - Country:US
Practice Address - Phone:513-460-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-23
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962828889OtherCLEVELAND CLINIC FLORIDA