Provider Demographics
NPI:1104127554
Name:BIOSPORT PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:BIOSPORT PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEOVARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, DPT, ATC
Authorized Official - Phone:209-524-7488
Mailing Address - Street 1:PO BOX 576751
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6751
Mailing Address - Country:US
Mailing Address - Phone:209-524-7488
Mailing Address - Fax:209-522-7488
Practice Address - Street 1:4341 SPYRES WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9259
Practice Address - Country:US
Practice Address - Phone:209-524-7488
Practice Address - Fax:209-522-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27941261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ33696Medicare UPIN