Provider Demographics
NPI:1104427665
Name:SPORT LIFE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SPORT LIFE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:508-577-2279
Mailing Address - Street 1:21 VINE ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-2311
Mailing Address - Country:US
Mailing Address - Phone:508-577-2279
Mailing Address - Fax:
Practice Address - Street 1:21 VINE ST
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-2311
Practice Address - Country:US
Practice Address - Phone:508-577-2279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty