Provider Demographics
NPI:1104834050
Name:SPORTS LLC
Entity Type:Organization
Organization Name:SPORTS LLC
Other - Org Name:FYZICAL SPORTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-655-8535
Mailing Address - Street 1:9070 W. CHEYENNE AVE
Mailing Address - Street 2:STE. #100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129
Mailing Address - Country:US
Mailing Address - Phone:702-655-8535
Mailing Address - Fax:702-656-5863
Practice Address - Street 1:9070 W. CHEYENNE AVE
Practice Address - Street 2:SUITE. #100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129
Practice Address - Country:US
Practice Address - Phone:702-655-8535
Practice Address - Fax:702-656-5863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2005225100000X
NV0449225100000X
NV2004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV101520OtherMEDICARE GROUP
NVV101520Medicare PIN