Provider Demographics
NPI:1730562109
Name:CHIEF PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:CHIEF PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARSON
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTUCHIEF
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:954-256-9052
Mailing Address - Street 1:224 SE 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1020
Mailing Address - Country:US
Mailing Address - Phone:954-256-9052
Mailing Address - Fax:954-533-5275
Practice Address - Street 1:805 SE 3RD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1105
Practice Address - Country:US
Practice Address - Phone:954-256-9052
Practice Address - Fax:954-533-5275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QH0100X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty