Healthcare Provider Details

I. General information

NPI: 1568883536
Provider Name (Legal Business Name): OSTEOPATHIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 BISCAYNE BLVD STE 406
MIAMI FL
33137-3737
US

IV. Provider business mailing address

3915 BISCAYNE BLVD STE 406
MIAMI FL
33137-3737
US

V. Phone/Fax

Practice location:
  • Phone: 305-367-1176
  • Fax: 877-391-0039
Mailing address:
  • Phone: 305-367-1176
  • Fax: 877-391-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1037
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS10979
License Number StateFL

VIII. Authorized Official

Name: KRISTOPHER SEAN GODDARD
Title or Position: MGRM
Credential: D.O.
Phone: 305-367-1176