Provider Demographics
NPI:1104914597
Name:SPORTS AND ORTHOPEDIC SPECIALISTS
Entity type:Organization
Organization Name:SPORTS AND ORTHOPEDIC SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:510-547-8293
Mailing Address - Street 1:6300 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1329
Mailing Address - Country:US
Mailing Address - Phone:510-547-8293
Mailing Address - Fax:510-547-2102
Practice Address - Street 1:6300 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1329
Practice Address - Country:US
Practice Address - Phone:510-547-8293
Practice Address - Fax:510-547-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23942ZMedicare PIN