Provider Demographics
NPI:1821442146
Name:ULTIMATE EDGE SPORTS MEDICINE
Entity Type:Organization
Organization Name:ULTIMATE EDGE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:419-392-4394
Mailing Address - Street 1:1581 MONTGOMERY HWY STE 115
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35216-4536
Mailing Address - Country:US
Mailing Address - Phone:205-874-6765
Mailing Address - Fax:
Practice Address - Street 1:1581 MONTGOMERY HWY STE 115
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216-4536
Practice Address - Country:US
Practice Address - Phone:205-874-6765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH 6023261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy