Provider Demographics
NPI:1447615463
Name:MITCHELL SPORTS PERFORMANCE
Entity Type:Organization
Organization Name:MITCHELL SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-717-5050
Mailing Address - Street 1:4209 W HUNDRED RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1734
Mailing Address - Country:US
Mailing Address - Phone:804-717-5050
Mailing Address - Fax:
Practice Address - Street 1:4209 W HUNDRED RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1734
Practice Address - Country:US
Practice Address - Phone:804-717-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1315286251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services