1245273127 NPI number — SPORTS AND BACK REHABILITATION INC

Table of content: (NPI 1245273127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245273127 NPI number — SPORTS AND BACK REHABILITATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS AND BACK REHABILITATION INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245273127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 E MAPLE AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
LANGHORNE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19047-2859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-752-4553
Provider Business Mailing Address Fax Number:
215-752-0703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 E MAPLE AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LANGHORNE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19047-2859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-752-4553
Provider Business Practice Location Address Fax Number:
215-752-0703
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERS
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
215-752-4553

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0053616 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0423943000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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