Provider Demographics
NPI:1356550883
Name:SPORTS, ORTHOPEDICS & ACTIVE REHABILITATION, INC.
Entity type:Organization
Organization Name:SPORTS, ORTHOPEDICS & ACTIVE REHABILITATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIENNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUENAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:671-647-0110
Mailing Address - Street 1:224 FARENHOLT AVE
Mailing Address - Street 2:UR 1 BUILDING
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3224
Mailing Address - Country:US
Mailing Address - Phone:671-647-0110
Mailing Address - Fax:671-647-0112
Practice Address - Street 1:224 FARENHOLT AVE
Practice Address - Street 2:UR 1 BUILDING
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3224
Practice Address - Country:US
Practice Address - Phone:671-647-0110
Practice Address - Fax:671-647-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2010-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUGUAMPT016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty