Provider Demographics
NPI:1952645046
Name:ADVANCE SPORTS THERAPEUTICS
Entity Type:Organization
Organization Name:ADVANCE SPORTS THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CERVENKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:614-600-2252
Mailing Address - Street 1:2476 POWELL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-1749
Mailing Address - Country:US
Mailing Address - Phone:614-600-2252
Mailing Address - Fax:
Practice Address - Street 1:1200 STEELWOOD RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-1371
Practice Address - Country:US
Practice Address - Phone:614-600-2252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013936261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy