Provider Demographics
NPI:1922868314
Name:ACTION POTENTIAL, PLLC DBA BELLEVUE SPORTS MEDICINE
Entity Type:Organization
Organization Name:ACTION POTENTIAL, PLLC DBA BELLEVUE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-620-6225
Mailing Address - Street 1:31 TOWN CENTER SQ # 200
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-7040
Mailing Address - Country:US
Mailing Address - Phone:601-620-6225
Mailing Address - Fax:
Practice Address - Street 1:31 TOWN CENTER SQ # 200
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-7040
Practice Address - Country:US
Practice Address - Phone:601-620-6225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty