Provider Demographics
NPI:1790873883
Name:SPORTS MEDICINE AND TRAINING CENTER
Entity Type:Organization
Organization Name:SPORTS MEDICINE AND TRAINING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:R.
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:VAN NEST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-961-3787
Mailing Address - Street 1:119 WATSON PLAZA
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1962
Mailing Address - Country:US
Mailing Address - Phone:314-961-3787
Mailing Address - Fax:314-961-0974
Practice Address - Street 1:119 WATSON PLAZA
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1962
Practice Address - Country:US
Practice Address - Phone:314-961-3787
Practice Address - Fax:314-961-0974
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS MEDICINE AND TRAINING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990001744Medicare ID - Type UnspecifiedMISSOURI MEDICARE