Healthcare Provider Details

I. General information

NPI: 1801098769
Provider Name (Legal Business Name): PRO-TECH SPORTS MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7241 SW 63RD AVE SUITE 102A
SOUTH MIAMI FL
33143-4838
US

IV. Provider business mailing address

7241 SW 63RD AVE SUITE 102A
SOUTH MIAMI FL
33143-4838
US

V. Phone/Fax

Practice location:
  • Phone: 305-668-2860
  • Fax: 305-668-2862
Mailing address:
  • Phone: 305-668-2860
  • Fax: 305-668-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberP02792
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberP02027
License Number StateFL

VIII. Authorized Official

Name: MS. MELISSA LEEDS
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-668-2860