1356550883 NPI number — SPORTS, ORTHOPEDICS & ACTIVE REHABILITATION, INC.

Table of content: (NPI 1356550883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356550883 NPI number — SPORTS, ORTHOPEDICS & ACTIVE REHABILITATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS, ORTHOPEDICS & ACTIVE 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:
6
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:
1356550883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 FARENHOLT AVE
Provider Second Line Business Mailing Address:
UR 1 BUILDING
Provider Business Mailing Address City Name:
TAMUNING
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96913-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
671-647-0110
Provider Business Mailing Address Fax Number:
671-647-0112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 FARENHOLT AVE
Provider Second Line Business Practice Location Address:
UR 1 BUILDING
Provider Business Practice Location Address City Name:
TAMUNING
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96913-3224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-647-0110
Provider Business Practice Location Address Fax Number:
671-647-0112
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUENAS
Authorized Official First Name:
JULIENNE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
671-647-0110

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  GUAMPT016 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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