Provider Demographics
NPI:1861682148
Name:NELA SPORTCENTER, L.L.C.
Entity Type:Organization
Organization Name:NELA SPORTCENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:PONDER
Authorized Official - Suffix:
Authorized Official - Credentials:LOTR
Authorized Official - Phone:318-329-8998
Mailing Address - Street 1:307 REGISTER ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-2737
Mailing Address - Country:US
Mailing Address - Phone:318-329-8998
Mailing Address - Fax:318-329-8997
Practice Address - Street 1:307 REGISTER ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-2737
Practice Address - Country:US
Practice Address - Phone:318-329-8998
Practice Address - Fax:318-329-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation