Basic Information
| Provider Information | |||||||||
| NPI: | 1639194152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALEXANDRIA SPORTS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PATRIOT SPORTSMEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157015245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244653496 | ||||||||
| FaxNumber: | 2154134682 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 WESTPARK DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221023114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035568477 | ||||||||
| FaxNumber: | 7035568486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POOL | ||||||||
| AuthorizedOfficialFirstName: | JAYNE | ||||||||
| AuthorizedOfficialMiddleName: | FLECK | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4694678705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.