Healthcare Provider Details

I. General information

NPI: 1811766637
Provider Name (Legal Business Name): TRIDENT SPORTS MEDICINE AND REHABILITATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 HULL RD UNIT 12
ORMOND BEACH FL
32174-0738
US

IV. Provider business mailing address

873 HULL RD UNIT 12
ORMOND BEACH FL
32174-0738
US

V. Phone/Fax

Practice location:
  • Phone: 386-267-2965
  • Fax: 386-603-6007
Mailing address:
  • Phone: 386-267-2965
  • Fax: 386-603-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL F LYNCH
Title or Position: PRESIDENT
Credential: DPT
Phone: 570-762-3953