Provider Demographics
NPI:1700188463
Name:SOUTHERN OHIO SPORTS MEDICINE AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SOUTHERN OHIO SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Name:SOUTHERN OHIO SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:937-587-9422
Mailing Address - Street 1:118 RARDEN RD
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-1049
Mailing Address - Country:US
Mailing Address - Phone:937-587-9422
Mailing Address - Fax:937-587-9522
Practice Address - Street 1:118 RARDEN RD
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-1049
Practice Address - Country:US
Practice Address - Phone:937-587-9422
Practice Address - Fax:937-587-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 5740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty