1548533417 NPI number — ATHLETES ULTIMATE PERFORMANCE SPORTS & REHAB,LLC

Table of content: KARISSA LAUREN MONTANEZ LAC (NPI 1245052695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548533417 NPI number — ATHLETES ULTIMATE PERFORMANCE SPORTS & REHAB,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHLETES ULTIMATE PERFORMANCE SPORTS & REHAB,LLC
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:
1548533417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2350 NALL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT NECHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77651-4204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-722-1030
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 NALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT NECHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77651-4204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-722-1030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DAIGLE
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
409-722-1030

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  11964 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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