Healthcare Provider Details

I. General information

NPI: 1669984977
Provider Name (Legal Business Name): SPORTS CHIRO AND REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 S UNIVERSITY DR STE 603
DAVIE FL
33328-5314
US

IV. Provider business mailing address

5400 S UNIVERSITY DR STE 603
DAVIE FL
33328-5314
US

V. Phone/Fax

Practice location:
  • Phone: 954-900-2942
  • Fax: 954-451-3948
Mailing address:
  • Phone: 954-900-2942
  • Fax: 954-451-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9220
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: KIM TESTA
Title or Position: OFFICE MANAGER
Credential:
Phone: 954-451-3946