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General NPI Number Information
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NPI Number | 1679374110
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Entity Type | Organization
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Legal Business Name | BAYSIDE SPORT & SPINE PLLC
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Dates
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Enumeration Date | 03/21/2025
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Last Update Date | 07/02/2025
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Provider Practice Location Address
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Address Line | 5415 4TH ST N
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City | ST PETERSBURG
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State | FL
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Zip | 33703-2249
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Country | US
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Telephone | 727-521-4244
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Fax |
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Provider Business Mailing Address
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Address Line | 5415 4TH ST N
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City | ST PETERSBURG
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State | FL
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Zip | 33703-2249
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Country | US
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Telephone | 727-521-4244
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Fax |
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. ROSS J REVELLA
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Credential | DC
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Telephone | 330-261-3802
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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