Healthcare Provider Details

I. General information

NPI: 1306739982
Provider Name (Legal Business Name): EMPOWER SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

142 SAGE HEN DR
ST AUGUSTINE FL
32095-0048
US

IV. Provider business mailing address

142 SAGE HEN DR
ST AUGUSTINE FL
32095-0048
US

V. Phone/Fax

Practice location:
  • Phone: 904-323-1915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK ALLEN SMOTHERMON
Title or Position: OWNER
Credential: PT, DPT, ATC
Phone: 904-323-1915