Provider Demographics
NPI:1225073521
Name:SPORTS MED DENTON LLC
Entity Type:Organization
Organization Name:SPORTS MED DENTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-380-9111
Mailing Address - Street 1:2318 SAN JACINTO BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7535
Mailing Address - Country:US
Mailing Address - Phone:940-380-9111
Mailing Address - Fax:940-380-9112
Practice Address - Street 1:2318 SAN JACINTO BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7535
Practice Address - Country:US
Practice Address - Phone:940-380-9111
Practice Address - Fax:940-380-9112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX652180000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00528YMedicare ID - Type Unspecified