Provider Demographics
NPI:1093334039
Name:SPORT IS RELIGION
Entity Type:Organization
Organization Name:SPORT IS RELIGION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:BREANNA
Authorized Official - Middle Name:N
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-785-7348
Mailing Address - Street 1:8641 LAS VEGAS CT APT 2722
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0044
Mailing Address - Country:US
Mailing Address - Phone:682-785-7348
Mailing Address - Fax:
Practice Address - Street 1:8641 LAS VEGAS CT APT 2722
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-0044
Practice Address - Country:US
Practice Address - Phone:682-785-7348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty