MEDICARE: CHIEF PHYSICAL THERAPY AND SPORTS MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center		FL
2	261QP2000X	Physical Therapy Clinic/Center		FL

General Provider Information

NPI Number	:	1730562109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIEF PHYSICAL THERAPY AND SPORTS MEDICINE LLC

Provider Business Mailing Address
First Line	:	224 SE 9TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-1020
Country	:	US
Telephone Number	:	954-256-9052
Fax Number	:	954-533-5275

Provider Business Practice Location Address
First Line	:	805 SE 3RD AVE
Second Line	:	SUITE 2
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-1105
Country	:	US
Telephone Number	:	954-256-9052
Fax Number	:	954-533-5275

Authorized Official
Title or Position	:	MANAGING MEMBER/OWNER
Name	:	CARSON KUTUCHIEF
Credential	:	P.T.
Telephone Number	:	954-256-9052

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	03/23/2022

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