Provider Demographics
NPI:1215171079
Name:ACTIVE SPORTS MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:ACTIVE SPORTS MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:305-275-6346
Mailing Address - Street 1:9335 SW 68TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-2324
Mailing Address - Country:US
Mailing Address - Phone:305-275-6346
Mailing Address - Fax:305-275-6347
Practice Address - Street 1:5995 SW 71ST ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3500
Practice Address - Country:US
Practice Address - Phone:305-275-6346
Practice Address - Fax:305-275-6347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7854225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty