Provider Demographics
NPI:1477832897
Name:ORTHOSPORT
Entity type:Organization
Organization Name:ORTHOSPORT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT,ATC
Authorized Official - Phone:561-328-9298
Mailing Address - Street 1:8371 N MILITARY TRL
Mailing Address - Street 2:#106
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6300
Mailing Address - Country:US
Mailing Address - Phone:561-328-9298
Mailing Address - Fax:561-328-9348
Practice Address - Street 1:8371 N MILITARY TRL
Practice Address - Street 2:#106
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-6300
Practice Address - Country:US
Practice Address - Phone:561-328-9298
Practice Address - Fax:561-328-9348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19952302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization