Healthcare Provider Details

I. General information

NPI: 1093632093
Provider Name (Legal Business Name): PROFORMANCE SPORTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 N GOMEZ AVE STE B
TAMPA FL
33607-6311
US

IV. Provider business mailing address

3817 W SAN NICHOLAS ST
TAMPA FL
33629-6307
US

V. Phone/Fax

Practice location:
  • Phone: 773-957-6841
  • Fax:
Mailing address:
  • Phone: 773-957-6841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN SILVER
Title or Position: MEMBER
Credential: PT, ATC, CSCS
Phone: 773-957-6841