Healthcare Provider Details

I. General information

NPI: 1740662410
Provider Name (Legal Business Name): SPINE, SPORT & PHYSICAL MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 BEE RIDGE RD SUITE B
SARASOTA FL
34239-6108
US

IV. Provider business mailing address

2030 BEE RIDGE RD SUITE B
SARASOTA FL
34239-6108
US

V. Phone/Fax

Practice location:
  • Phone: 941-845-0233
  • Fax: 941-538-6063
Mailing address:
  • Phone: 941-845-0233
  • Fax: 941-538-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLOS A DIAZ
Title or Position: OWNER
Credential: MD
Phone: 941-809-5794