=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487548129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHLETE BY DESIGN YOUTH SPORTS FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2025
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18605 NW 27TH AVE
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33056-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-987-1113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E LAS OLAS BLVD STE 130
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-2477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-987-1113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | BRYANT BURTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-987-1113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------