Provider Demographics
NPI:1184020653
Name:SPORTS,ORTHOPEDICS & ACTIVE REHABILITATION
Entity Type:Organization
Organization Name:SPORTS,ORTHOPEDICS & ACTIVE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIENNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUENAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-647-0110
Mailing Address - Street 1:224 FARENHOLT AVENUE
Mailing Address - Street 2:UR 1 BUILDING
Mailing Address - City:TAMUNING
Mailing Address - State:GUAM
Mailing Address - Zip Code:96913
Mailing Address - Country:AX
Mailing Address - Phone:671-647-0110
Mailing Address - Fax:
Practice Address - Street 1:224 FARENHOLT AVENUE
Practice Address - Street 2:UR 1 BUILDING
Practice Address - City:TAMUNING
Practice Address - State:GUAM
Practice Address - Zip Code:96913
Practice Address - Country:AX
Practice Address - Phone:671-647-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPT-37171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty