Provider Demographics
NPI:1366884496
Name:SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC
Entity type:Organization
Organization Name:SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACEE
Authorized Official - Middle Name:LEIANN
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:352-243-9700
Mailing Address - Street 1:1925 DON WICKHAM DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1915
Mailing Address - Country:US
Mailing Address - Phone:352-243-9700
Mailing Address - Fax:352-243-5795
Practice Address - Street 1:1925 DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1915
Practice Address - Country:US
Practice Address - Phone:352-243-9700
Practice Address - Fax:352-243-5795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037707207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty