Provider Demographics
NPI:1104408533
Name:TRUST ORTHOPEDIC AND SPORTS REHAB LLC
Entity type:Organization
Organization Name:TRUST ORTHOPEDIC AND SPORTS REHAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:MALAK KHALIL
Authorized Official - Last Name:SHEHATA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:727-953-3031
Mailing Address - Street 1:29251 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2102
Mailing Address - Country:US
Mailing Address - Phone:727-953-3031
Mailing Address - Fax:727-264-1542
Practice Address - Street 1:29251 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2102
Practice Address - Country:US
Practice Address - Phone:727-953-3031
Practice Address - Fax:727-264-1542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32409OtherFLORIDA LICENSE