Provider Demographics
NPI:1134242951
Name:SPORTS MEDICINE AND PHYSICAL THERAPY CENTER
Entity type:Organization
Organization Name:SPORTS MEDICINE AND PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MENDLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:765-457-1443
Mailing Address - Street 1:402 S BERKLEY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-5172
Mailing Address - Country:US
Mailing Address - Phone:765-457-1443
Mailing Address - Fax:765-457-4990
Practice Address - Street 1:402 S BERKLEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5172
Practice Address - Country:US
Practice Address - Phone:765-457-1443
Practice Address - Fax:765-457-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005052A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty