Provider Demographics
NPI:1063009272
Name:SPORTS AND REHABILITATION CENTER OF WYOMING LLC
Entity Type:Organization
Organization Name:SPORTS AND REHABILITATION CENTER OF WYOMING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMESFAHR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-307-9670
Mailing Address - Street 1:522 N SWEETZER AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2659
Mailing Address - Country:US
Mailing Address - Phone:310-307-9670
Mailing Address - Fax:
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-920-1688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-22
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty