Provider Demographics
NPI:1740662410
Name:SPINE, SPORT & PHYSICAL MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:SPINE, SPORT & PHYSICAL MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-809-5794
Mailing Address - Street 1:2030 BEE RIDGE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6108
Mailing Address - Country:US
Mailing Address - Phone:941-845-0233
Mailing Address - Fax:941-538-6063
Practice Address - Street 1:2030 BEE RIDGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6108
Practice Address - Country:US
Practice Address - Phone:941-845-0233
Practice Address - Fax:941-538-6063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty