Basic Information
| Provider Information | |||||||||
| NPI: | 1275204083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POWER PLAY SPORTS & THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11705 BOYETTE RD STE 420 | ||||||||
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| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335695533 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11907 SHADOW RUN BLVD | ||||||||
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| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133742209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2021 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8133742209 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.