Provider Demographics
NPI:1649656000
Name:481 SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:481 SPORTS MEDICINE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNATHON
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:281-395-4121
Mailing Address - Street 1:1450 W GRAND PKWY S
Mailing Address - Street 2:#G-414
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-8286
Mailing Address - Country:US
Mailing Address - Phone:281-394-9100
Mailing Address - Fax:
Practice Address - Street 1:481 S KATY FORT BEND RD
Practice Address - Street 2:SUITE 210
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-0815
Practice Address - Country:US
Practice Address - Phone:281-394-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5270111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty