Provider Demographics
NPI:1639486947
Name:EL PASO SPORTS MEDICINE CENTER LLC
Entity Type:Organization
Organization Name:EL PASO SPORTS MEDICINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER ATHLETIC TRAINER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTY
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:915-590-9990
Mailing Address - Street 1:11163 LA QUINTA PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5255
Mailing Address - Country:US
Mailing Address - Phone:915-590-9990
Mailing Address - Fax:915-590-9996
Practice Address - Street 1:11163 LA QUINTA PL
Practice Address - Street 2:SUITE C
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5255
Practice Address - Country:US
Practice Address - Phone:915-590-9990
Practice Address - Fax:915-590-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT4431261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center