Provider Demographics
NPI:1073158655
Name:PERFORMANCE SPORTS MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:PERFORMANCE SPORTS MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-335-9140
Mailing Address - Street 1:6535 S DAYTON ST STE 3100
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-6134
Mailing Address - Country:US
Mailing Address - Phone:303-335-9140
Mailing Address - Fax:
Practice Address - Street 1:6535 S DAYTON ST STE 3100
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-6134
Practice Address - Country:US
Practice Address - Phone:303-335-9140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty