=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538955281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE THERAPIST SPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14750 NW 77TH CT STE 304B
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-801-4030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14750 NW 77TH CT STE 304B
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-801-4030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ALFONSO GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-801-4030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273Y00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WW0000X
-----------------------------------------------------
Taxonomy Name | Wound Care Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------