Healthcare Provider Details

I. General information

NPI: 1033701123
Provider Name (Legal Business Name): ALLIANCE SPORTS REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 2ND AVE NE STE 1401
ST PETERSBURG FL
33701-3480
US

IV. Provider business mailing address

111 2ND AVE NE STE 1401
ST PETERSBURG FL
33701-3480
US

V. Phone/Fax

Practice location:
  • Phone: 727-258-7224
  • Fax:
Mailing address:
  • Phone: 727-258-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRIAN BROUSSARD
Title or Position: CO-OWNER
Credential: DPT
Phone: 727-258-7224