=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568980621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE SPORT & ALL FACETS OF REHAB CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 08/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 BLUESTONE PL
-----------------------------------------------------
City | CASSELBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32707-4147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-731-4618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 BLUESTONE PL
-----------------------------------------------------
City | CASSELBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32707-4147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-731-4618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AO
-----------------------------------------------------
Name | DR. SOOFIA KHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-731-4618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------