Provider Demographics
NPI:1740557776
Name:SPORT & SPINAL REHAB
Entity type:Organization
Organization Name:SPORT & SPINAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:NEVEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-746-4242
Mailing Address - Street 1:275 TONEY PENNA DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5752
Mailing Address - Country:US
Mailing Address - Phone:561-746-4242
Mailing Address - Fax:561-746-7405
Practice Address - Street 1:275 TONEY PENNA DR
Practice Address - Street 2:SUITE 12
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5752
Practice Address - Country:US
Practice Address - Phone:561-746-4242
Practice Address - Fax:561-746-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty