Provider Demographics
NPI:1760466601
Name:SPORTS & ORTHOPAEDIC ASSOCIATES OF THE REDLANDS, LLC
Entity Type:Organization
Organization Name:SPORTS & ORTHOPAEDIC ASSOCIATES OF THE REDLANDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRITT
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MSP OCS FAAOPT
Authorized Official - Phone:970-263-4079
Mailing Address - Street 1:2497 POWER RD
Mailing Address - Street 2:UNIT 10
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-3085
Mailing Address - Country:US
Mailing Address - Phone:970-263-4079
Mailing Address - Fax:970-241-2595
Practice Address - Street 1:2497 POWER RD
Practice Address - Street 2:UNIT 10
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81507-3085
Practice Address - Country:US
Practice Address - Phone:970-263-4079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCF8038OtherRAILROAD MEDICARE PIN
COC8803Medicare PIN