Provider Demographics
NPI:1609186485
Name:THE SPORTS CENTRE, LLC
Entity Type:Organization
Organization Name:THE SPORTS CENTRE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-456-1780
Mailing Address - Street 1:151 STORRS ROAD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1638
Mailing Address - Country:US
Mailing Address - Phone:860-456-1780
Mailing Address - Fax:860-456-1976
Practice Address - Street 1:5 FOUNDERS ST STE 204
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2057
Practice Address - Country:US
Practice Address - Phone:860-456-1780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2017-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT47438207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty