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General NPI Number Information
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NPI Number | 1215377569
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Entity Type | Organization
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Legal Business Name | EXTREME SPORTS MEDICINE & REHABILITATION INC
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Dates
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Enumeration Date | 07/01/2013
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Last Update Date | 08/14/2019
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Provider Practice Location Address
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Address Line | 14125 NW 80TH AVE STE 203
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City | MIAMI LAKES
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State | FL
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Zip | 33016-2351
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Country | US
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Telephone | 305-381-5357
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Fax | 305-846-9653
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Provider Business Mailing Address
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Address Line | 4393 SW 130TH AVE
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City | DAVIE
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State | FL
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Zip | 33330-4730
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Country | US
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Telephone | 954-665-7326
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Fax | 305-846-9653
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. SEAN WILLIAMS
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Credential | MPT
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Telephone | 954-665-7326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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