Provider Demographics
NPI:1700823044
Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-897-3334
Mailing Address - Street 1:610 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539
Mailing Address - Country:US
Mailing Address - Phone:850-683-0077
Mailing Address - Fax:850-683-0099
Practice Address - Street 1:610 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-7356
Practice Address - Country:US
Practice Address - Phone:850-683-0077
Practice Address - Fax:850-683-0099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY906YOtherBCBSFL GROUP#
FL8913153-02Medicaid
FL8913153-02Medicaid