Healthcare Provider Details

I. General information

NPI: 1700823044
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 HOSPITAL DR
CRESTVIEW FL
32539-7356
US

IV. Provider business mailing address

610 HOSPITAL DRIVE
CRESTVIEW FL
32539
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-0077
  • Fax: 850-683-0099
Mailing address:
  • Phone: 850-683-0077
  • Fax: 850-683-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NICOLE SHEPPARD
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 850-897-3334