Provider Demographics
NPI:1750100723
Name:PRESTIGE SPORTS AND REGENERATIVE MEDICINE LLC
Entity type:Organization
Organization Name:PRESTIGE SPORTS AND REGENERATIVE MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-485-3166
Mailing Address - Street 1:3800 W BROWARD BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1018
Mailing Address - Country:US
Mailing Address - Phone:954-787-5234
Mailing Address - Fax:954-820-4479
Practice Address - Street 1:3800 W BROWARD BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1018
Practice Address - Country:US
Practice Address - Phone:469-915-4211
Practice Address - Fax:954-820-4479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty