1508078809 NPI number — SPORTS THERAPY CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508078809 NPI number — SPORTS THERAPY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS THERAPY CENTER
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:
1508078809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 E LAYFAIR DR
Provider Second Line Business Mailing Address:
STE 125
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-7604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-420-6867
Provider Business Mailing Address Fax Number:
601-664-1006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E LAYFAIR DR
Provider Second Line Business Practice Location Address:
STE 125
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-420-6867
Provider Business Practice Location Address Fax Number:
601-664-1006
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
UPTON
Authorized Official First Name:
RENAE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
601-420-6867

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT1265 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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