Healthcare Provider Details

I. General information

NPI: 1740928548
Provider Name (Legal Business Name): ORTHO FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 JOHN F KENNEDY DR STE 204
ATLANTIS FL
33462-6633
US

IV. Provider business mailing address

433 PLAZA REAL STE 275
BOCA RATON FL
33432-3999
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-9511
  • Fax:
Mailing address:
  • Phone: 561-300-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DANE TRASK
Title or Position: CEO
Credential:
Phone: 813-747-1128