Provider Demographics
NPI:1396079224
Name:SPORTS MEDICINE AND REHAB THERAPY, LLC
Entity type:Organization
Organization Name:SPORTS MEDICINE AND REHAB THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-285-0053
Mailing Address - Street 1:301 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5229
Mailing Address - Country:US
Mailing Address - Phone:912-285-0053
Mailing Address - Fax:
Practice Address - Street 1:301 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5229
Practice Address - Country:US
Practice Address - Phone:912-285-0053
Practice Address - Fax:912-283-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA390574913NMedicaid
GA390574913NMedicaid