1730382391 NPI number — SPORT MED PHYSICAL THERAPY

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 1730382391 NPI number — SPORT MED PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORT MED PHYSICAL THERAPY
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:
1730382391
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:
6925 SHALLOWFORD RD
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-1787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-322-9523
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6925 SHALLOWFORD RD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-1787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-322-9523
Provider Business Practice Location Address Fax Number:
423-847-0059
Provider Enumeration Date:
06/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FAULKNER
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-322-9523

Provider Taxonomy Codes

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

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





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