Healthcare Provider Details

I. General information

NPI: 1447753942
Provider Name (Legal Business Name): SPORTS AND ORTHOPEDIC CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 N FEDERAL HWY
BOCA RATON FL
33431-5135
US

IV. Provider business mailing address

6280 W SAMPLE RD STE 203
CORAL SPRINGS FL
33067-3173
US

V. Phone/Fax

Practice location:
  • Phone: 561-220-2622
  • Fax:
Mailing address:
  • Phone: 954-481-9942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MANISH K GUPTA
Title or Position: CEO
Credential:
Phone: 561-314-7200