Provider Demographics
NPI:1992917892
Name:SPORTS ORTHOPEDIC REHAB TEAM
Entity type:Organization
Organization Name:SPORTS ORTHOPEDIC REHAB TEAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:I
Authorized Official - Credentials:PT
Authorized Official - Phone:727-441-4549
Mailing Address - Street 1:16104 REDINGTON DR.
Mailing Address - Street 2:
Mailing Address - City:REDINGTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708
Mailing Address - Country:US
Mailing Address - Phone:210-710-9279
Mailing Address - Fax:
Practice Address - Street 1:812 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756
Practice Address - Country:US
Practice Address - Phone:727-441-4549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17700261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service