Provider Demographics
NPI:1275786469
Name:SPORTS, BACK & PAIN MANGEMENT CLINIC
Entity Type:Organization
Organization Name:SPORTS, BACK & PAIN MANGEMENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-776-2225
Mailing Address - Street 1:2011 #A VILLA MARIA RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2541
Mailing Address - Country:US
Mailing Address - Phone:979-776-2225
Mailing Address - Fax:979-776-7945
Practice Address - Street 1:2011 #A VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2541
Practice Address - Country:US
Practice Address - Phone:979-776-2225
Practice Address - Fax:979-776-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1055085225100000X, 2251E1300X, 2251G0304X, 2251H1300X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Single Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
No2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman FactorsGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty