Provider Demographics
NPI:1699941401
Name:SUNCOAST SPORTS AND ORTHOPEDIC THERAPY, INC
Entity type:Organization
Organization Name:SUNCOAST SPORTS AND ORTHOPEDIC THERAPY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:WHITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:727-345-3346
Mailing Address - Street 1:40 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8408
Mailing Address - Country:US
Mailing Address - Phone:727-345-3346
Mailing Address - Fax:727-345-3595
Practice Address - Street 1:3690 E BAY DR
Practice Address - Street 2:SUITE S
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-5903
Practice Address - Country:US
Practice Address - Phone:727-532-0005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5232Medicare UPIN