Basic Information
| Provider Information | |||||||||
| NPI: | 1134259252 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPORTS THERAPY & REHABILITATION CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 84 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787410880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 84 HIGHLAND AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787410880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 11/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9787410880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 135 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 0368989 | 05 | MA | MEDICAID | Y61051 | 01 | MA | BLUE CROSS / BLUE SHIELD | OTHER | AA68907 | 01 | MA | HARVARD PILGRIM | OTHER |