=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568914117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SARASOTA CENTER FOR PHYSICAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2016
-----------------------------------------------------
Last Update Date | 02/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7222 S TAMIAMI TRL
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34231-5567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-921-4884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7222 S TAMIAMI TRL 105
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34231-5567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-921-4884
-----------------------------------------------------
Fax | 941-921-4883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUSTIN M DURFEE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 941-921-4884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | CH11310
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------