Healthcare Provider Details

I. General information

NPI: 1023539574
Provider Name (Legal Business Name): ORTHO FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5966 S DIXIE HWY STE 401
SOUTH MIAMI FL
33143-5177
US

IV. Provider business mailing address

PO BOX 978766
DALLAS TX
75397-8766
US

V. Phone/Fax

Practice location:
  • Phone: 786-453-2667
  • Fax:
Mailing address:
  • Phone: 561-300-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DANE TRASK
Title or Position: CEO
Credential:
Phone: 813-787-1128