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General NPI Number Information
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NPI Number | 1114744067
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Entity Type | Organization
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Legal Business Name | BRANDON SPORTS AND AQUATICS CENTER, INC.
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Dates
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Enumeration Date | 09/23/2024
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Last Update Date | 01/07/2025
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Provider Practice Location Address
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Address Line | 405 BEVERLY BLVD
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City | BRANDON
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State | FL
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Zip | 33511-5507
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Country | US
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Telephone | 813-689-0908
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Fax |
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Provider Business Mailing Address
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Address Line | 405 BEVERLY BLVD
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City | BRANDON
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State | FL
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Zip | 33511-5507
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Country | US
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Telephone | 813-689-0908
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. CHARLES W. BURGESS JR.
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Credential |
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Telephone | 813-689-0908
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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