Provider Demographics
NPI:1376690214
Name:SMART SPORTS MEDICINE CLINIC PC
Entity type:Organization
Organization Name:SMART SPORTS MEDICINE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-632-7677
Mailing Address - Street 1:PO BOX 20168
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7004
Mailing Address - Country:US
Mailing Address - Phone:307-632-7677
Mailing Address - Fax:307-778-8292
Practice Address - Street 1:5307 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4736
Practice Address - Country:US
Practice Address - Phone:307-632-7677
Practice Address - Fax:307-778-8292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYE12254Medicare UPIN