Healthcare Provider Details

I. General information

NPI: 1881036697
Provider Name (Legal Business Name): ATLANTIC SPORT & SPINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 BOULDER ROCK DR
PALM COAST FL
32137-8555
US

IV. Provider business mailing address

3 BOULDER ROCK DR
PALM COAST FL
32137-8555
US

V. Phone/Fax

Practice location:
  • Phone: 386-445-9444
  • Fax:
Mailing address:
  • Phone: 386-445-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME98460
License Number StateFL

VIII. Authorized Official

Name: DR. MICHAEL SANDBORN
Title or Position: PRESIDENT
Credential: MD
Phone: 386-445-9444