Basic Information
| Provider Information | |||||||||
| NPI: | 1306900766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPORTS PLUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 TOOLEBECK RD | ||||||||
| Address2: | |||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298039679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036442020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 170 UNIVERSITY PKWY | ||||||||
| Address2: | |||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298016308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036499975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAYNARD | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PTA | ||||||||
| AuthorizedOfficialTelephone: | 8036499975 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA.1861 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.