Provider Demographics
NPI:1629419163
Name:SPORTS MANAGEMENT INSTITUTE LLC
Entity Type:Organization
Organization Name:SPORTS MANAGEMENT INSTITUTE LLC
Other - Org Name:SPORTS MEDICINE 360 LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGREGORIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-748-0067
Mailing Address - Street 1:14-20 WATSESSING AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4611
Mailing Address - Country:US
Mailing Address - Phone:973-748-0067
Mailing Address - Fax:
Practice Address - Street 1:14-20 WATSESSING AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-4611
Practice Address - Country:US
Practice Address - Phone:973-748-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0400560133207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty