Provider Demographics
NPI:1508480518
Name:SPORTS ENHANCEMENT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SPORTS ENHANCEMENT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY-KAY
Authorized Official - Middle Name:AUDRA
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:540-308-3358
Mailing Address - Street 1:2607 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-5726
Mailing Address - Country:US
Mailing Address - Phone:540-308-3358
Mailing Address - Fax:
Practice Address - Street 1:2607 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-5726
Practice Address - Country:US
Practice Address - Phone:540-308-3357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty