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General NPI Number Information
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NPI Number | 1053505529
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Entity Type | Organization
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Legal Business Name | OMEGA 40 SPORTS MEDICINE
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Dates
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Enumeration Date | 08/28/2007
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Last Update Date | 08/28/2007
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Provider Practice Location Address
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Address Line | 1 S OLD KINGS RD
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City | ORMOND BEACH
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State | FL
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Zip | 32174-6177
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Country | US
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Telephone | 386-672-4080
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Fax | 386-672-6197
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Provider Business Mailing Address
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Address Line | 1 S OLD KINGS RD
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City | ORMOND BEACH
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State | FL
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Zip | 32174-6177
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Country | US
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Telephone | 386-672-4080
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Fax | 386-672-6197
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Authorized Official
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Title or Position | OWNER
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Name | STEVE XYNIDIS
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Credential | R.P.T.
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Telephone | 386-672-4080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT0000766
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License Number State | FL
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