Provider Demographics
NPI:1548428931
Name:BOOST SPORTS PERFORMANCE, LLC
Entity Type:Organization
Organization Name:BOOST SPORTS PERFORMANCE, LLC
Other - Org Name:BOOST PHYSICAL THERAPY & SPORTS PERFORMANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LINVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, SCS
Authorized Official - Phone:816-407-1249
Mailing Address - Street 1:1254 SE CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-3286
Mailing Address - Country:US
Mailing Address - Phone:816-524-1442
Mailing Address - Fax:816-524-1445
Practice Address - Street 1:1254 SE CENTURY DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-3286
Practice Address - Country:US
Practice Address - Phone:816-524-1442
Practice Address - Fax:816-524-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1102OtherMEDICARE PTAN
MOMA5234OtherMEDICARE PTAN