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General NPI Number Information
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NPI Number | 1972042257
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Entity Type | Organization
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Legal Business Name | 3D SPORTS MEDICINE AND ORTHOPAEDIC CENTER
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Dates
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Enumeration Date | 02/20/2017
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Last Update Date | 02/20/2017
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Provider Practice Location Address
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Address Line | 2194 HIGHWAY A1A STE 104
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City | INDIAN HARBOUR BEACH
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State | FL
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Zip | 32937-4955
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Country | US
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Telephone | 321-610-8939
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Fax |
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Provider Business Mailing Address
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Address Line | 2231 HAMPTON GREEN BLVD APT 105
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City | MELBOURNE
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State | FL
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Zip | 32935
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Country | US
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Telephone | 540-250-3085
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Fax |
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Authorized Official
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Title or Position | ATHLETIC TRAINER/PHYSICIAN EXTENDER
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Name | MR. BRANDON HUDNALL
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Credential | LAT, ATC
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Telephone | 540-250-3085
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | AL4490
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License Number State | FL
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