Provider Demographics
NPI:1558585638
Name:TH E SPORTS MEDICINE STORE LLC
Entity Type:Organization
Organization Name:TH E SPORTS MEDICINE STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORELLI
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:518-522-0340
Mailing Address - Street 1:55 PITTSFIELD RD
Mailing Address - Street 2:BLDG #8B
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2122
Mailing Address - Country:US
Mailing Address - Phone:413-637-8326
Mailing Address - Fax:
Practice Address - Street 1:55 PITTSFIELD RD
Practice Address - Street 2:BLDG #8B
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2122
Practice Address - Country:US
Practice Address - Phone:413-637-8326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies