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General NPI Number Information
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NPI Number | 1366884496
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Entity Type | Organization
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Legal Business Name | SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC
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Dates
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Enumeration Date | 07/17/2013
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Last Update Date | 12/10/2013
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Provider Practice Location Address
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Address Line | 1925 DON WICKHAM DR
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City | CLERMONT
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State | FL
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Zip | 34711-1915
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Country | US
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Telephone | 352-243-9700
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Fax | 352-243-5795
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Provider Business Mailing Address
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Address Line | 1925 DON WICKHAM DR
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City | CLERMONT
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State | FL
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Zip | 34711-1915
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Country | US
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Telephone | 352-243-9700
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Fax | 352-243-5795
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Authorized Official
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Title or Position | PRESIDENT
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Name | TRACEE LEIANN RAY
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Credential | RN
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Telephone | 352-243-9700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | ME0037707
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License Number State | FL
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