Provider Demographics
NPI:1558512327
Name:SPORT & REHAB PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SPORT & REHAB PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-827-6178
Mailing Address - Street 1:312 W J ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4069
Mailing Address - Country:US
Mailing Address - Phone:209-827-6178
Mailing Address - Fax:209-827-6179
Practice Address - Street 1:312 W J ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4069
Practice Address - Country:US
Practice Address - Phone:209-827-6178
Practice Address - Fax:209-827-6179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23597261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy