Provider Demographics
NPI:1811766637
Name:TRIDENT SPORTS MEDICINE AND REHABILITATION INC.
Entity type:Organization
Organization Name:TRIDENT SPORTS MEDICINE AND REHABILITATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:570-762-3953
Mailing Address - Street 1:873 HULL RD UNIT 12
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-0738
Mailing Address - Country:US
Mailing Address - Phone:386-267-2965
Mailing Address - Fax:386-603-6007
Practice Address - Street 1:873 HULL RD UNIT 12
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-0738
Practice Address - Country:US
Practice Address - Phone:386-267-2965
Practice Address - Fax:386-603-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-20
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy