Healthcare Provider Details

I. General information

NPI: 1154960573
Provider Name (Legal Business Name): BRAINSPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 BURNS RD
PALM BEACH GARDENS FL
33410-5204
US

IV. Provider business mailing address

2525 BURNS RD
PALM BEACH GARDENS FL
33410-5204
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-7272
  • Fax: 772-337-7734
Mailing address:
  • Phone: 772-337-7272
  • Fax: 772-337-7734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: FRANCIS X CONIDI
Title or Position: CEO
Credential: D.O.
Phone: 772-337-7272