Provider Demographics
NPI:1952947285
Name:SPORTSEDGE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:SPORTSEDGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GERNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-451-3008
Mailing Address - Street 1:PO BOX 11147
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339-1147
Mailing Address - Country:US
Mailing Address - Phone:954-451-3002
Mailing Address - Fax:
Practice Address - Street 1:4800 NE 20TH TER STE 303
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4510
Practice Address - Country:US
Practice Address - Phone:954-771-8177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261QP2000XOtherTAXONOMY