Healthcare Provider Details

I. General information

NPI: 1134532054
Provider Name (Legal Business Name): SPINAL HEALTH AND REHAB OF PUNTA GORDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 CROSS ST
PUNTA GORDA FL
33950-4828
US

IV. Provider business mailing address

324 CROSS ST
PUNTA GORDA FL
33950-4828
US

V. Phone/Fax

Practice location:
  • Phone: 941-205-2180
  • Fax: 941-205-2181
Mailing address:
  • Phone: 941-205-2180
  • Fax: 941-205-2181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME 102997
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 18108
License Number StateFL

VIII. Authorized Official

Name: KEVIN VAN NOSTRAND
Title or Position: OWNER/OPERATOR
Credential: D.C.
Phone: 941-258-1965