Basic Information
| Provider Information | |||||||||
| NPI: | 1124395553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVENTURA ORTHO & SPORTS MED, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 GLADES RD | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613001779 | ||||||||
| FaxNumber: | 5613001879 | ||||||||
| Practice Location | |||||||||
| Address1: | 2260 NE 123RD STREET | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331812904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7869233000 | ||||||||
| FaxNumber: | 7869233002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | TRASK | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8137871128 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHO FLORIDA, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME86710 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.