Provider Demographics
NPI:1093979221
Name:SPORTSMED, P.C.
Entity Type:Organization
Organization Name:SPORTSMED, P.C.
Other - Org Name:DANIEL L. WYMER, D.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WYMER
Authorized Official - Suffix:SR
Authorized Official - Credentials:D,C
Authorized Official - Phone:757-200-2000
Mailing Address - Street 1:1004 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3070
Mailing Address - Country:US
Mailing Address - Phone:757-200-2000
Mailing Address - Fax:
Practice Address - Street 1:1004 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3070
Practice Address - Country:US
Practice Address - Phone:757-200-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1021Medicare PIN
VAT30790Medicare UPIN