Provider Demographics
NPI:1912082140
Name:FAMILY AND SPORTS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FAMILY AND SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETRICH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:702-968-0520
Mailing Address - Street 1:7351 PRAIRIE FALCON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0820
Mailing Address - Country:US
Mailing Address - Phone:702-968-0520
Mailing Address - Fax:702-968-0521
Practice Address - Street 1:7351 PRAIRIE FALCON RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0820
Practice Address - Country:US
Practice Address - Phone:702-968-0520
Practice Address - Fax:702-968-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV34783Medicare PIN