Healthcare Provider Details

I. General information

NPI: 1528203593
Provider Name (Legal Business Name): SSP MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 SAXON BLVD SUITE 204
DELTONA FL
32725-5876
US

IV. Provider business mailing address

1565 SAXON BLVD SUITE 204
DELTONA FL
32725-5876
US

V. Phone/Fax

Practice location:
  • Phone: 386-742-4343
  • Fax:
Mailing address:
  • Phone: 386-742-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME96564
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License NumberME96564
License Number StateFL

VIII. Authorized Official

Name: DR. ALEX KHROMOV
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-742-4343