Provider Demographics
NPI:1265441075
Name:SPORTS THERAPY AND ADVANCED REHABILITATION, INC.
Entity type:Organization
Organization Name:SPORTS THERAPY AND ADVANCED REHABILITATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILISSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-288-2700
Mailing Address - Street 1:7401 W HIGHWAY 71 STE 130
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8260
Mailing Address - Country:US
Mailing Address - Phone:512-288-2700
Mailing Address - Fax:512-288-2711
Practice Address - Street 1:7401 W HIGHWAY 71 STE 130
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8260
Practice Address - Country:US
Practice Address - Phone:512-288-2700
Practice Address - Fax:512-288-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651590000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0059JOtherBCBS ID
00965UMedicare PIN