Provider Demographics
NPI:1215903034
Name:PAL SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:PAL SPORTS MEDICINE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:LAINE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:561-746-4112
Mailing Address - Street 1:850 W INDIANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-746-4112
Mailing Address - Fax:561-575-6738
Practice Address - Street 1:850 W INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-746-4112
Practice Address - Fax:561-575-6738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2624Medicare PIN