Provider Demographics
NPI:1851980502
Name:WEBSTER SPORTS MEDICINE AND INJURY CLINIC LLC
Entity Type:Organization
Organization Name:WEBSTER SPORTS MEDICINE AND INJURY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCHOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-687-7494
Mailing Address - Street 1:202 N TEXAS AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 N TEXAS AVE STE 400
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4967
Practice Address - Country:US
Practice Address - Phone:806-701-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty