Provider Demographics
NPI:1003900820
Name:ORTHOPEDIC AND SPORTS ENHANCEMENT CENTER, LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC AND SPORTS ENHANCEMENT CENTER, LLC
Other - Org Name:SPORTS ENHANCEMENT CENTER, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J. ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUSTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-663-9300
Mailing Address - Street 1:2406 E EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3630
Mailing Address - Country:US
Mailing Address - Phone:309-663-9300
Mailing Address - Fax:309-661-1670
Practice Address - Street 1:2406 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3630
Practice Address - Country:US
Practice Address - Phone:309-663-9300
Practice Address - Fax:309-661-1670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL420960Medicare ID - Type Unspecified
IL4452310001Medicare NSC