Basic Information
| Provider Information | |||||||||
| NPI: | 1114408739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMART SPORTS MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5307 YELLOWSTONE RD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076327677 | ||||||||
| FaxNumber: | 3077788292 | ||||||||
| Practice Location | |||||||||
| Address1: | 5307 YELLOWSTONE RD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076327677 | ||||||||
| FaxNumber: | 3077788292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3076327677 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 3871A | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.