Provider Demographics
NPI:1831865237
Name:DAWG MENTALITY SPORTS PERFORMANCE LLC
Entity type:Organization
Organization Name:DAWG MENTALITY SPORTS PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CSCS
Authorized Official - Phone:919-698-7479
Mailing Address - Street 1:829 GOLDEN HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-7311
Mailing Address - Country:US
Mailing Address - Phone:919-698-7479
Mailing Address - Fax:
Practice Address - Street 1:829 GOLDEN HORSESHOE LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-7311
Practice Address - Country:US
Practice Address - Phone:919-698-7479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC30649936OtherNCDMV