=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700823044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPEDIC & SPORTS PHYSICAL THERAPY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 04/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 HOSPITAL DR
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32539-7356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-683-0077
-----------------------------------------------------
Fax | 850-683-0099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 HOSPITAL DRIVE
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-683-0077
-----------------------------------------------------
Fax | 850-683-0099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MS. NICOLE SHEPPARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-897-3334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------