Provider Demographics
NPI:1396054896
Name:PRIME SPORTS PHYSICAL THERAPY
Entity type:Organization
Organization Name:PRIME SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-342-8214
Mailing Address - Street 1:247 SW 8TH ST
Mailing Address - Street 2:#163
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3529
Mailing Address - Country:US
Mailing Address - Phone:646-342-8214
Mailing Address - Fax:
Practice Address - Street 1:2601 S BAYSHORE DR
Practice Address - Street 2:7TH FL GARAGE LEVEL
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-5417
Practice Address - Country:US
Practice Address - Phone:646-342-8214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty