Provider Demographics
NPI:1679130744
Name:MOJO SPORTCLINIC, LLC
Entity Type:Organization
Organization Name:MOJO SPORTCLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHANNES
Authorized Official - Middle Name:P
Authorized Official - Last Name:DUPLESSIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-536-5667
Mailing Address - Street 1:8401 SARENSEN CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-3393
Mailing Address - Country:US
Mailing Address - Phone:910-536-5667
Mailing Address - Fax:
Practice Address - Street 1:6859 MONUMENT DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-4178
Practice Address - Country:US
Practice Address - Phone:910-338-5545
Practice Address - Fax:910-338-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty