Provider Demographics
NPI:1154409381
Name:THE SPORTS REHABILITATION CENTER
Entity type:Organization
Organization Name:THE SPORTS REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DESTINY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-477-8888
Mailing Address - Street 1:555 10TH STREET NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5713
Mailing Address - Country:US
Mailing Address - Phone:404-477-8888
Mailing Address - Fax:404-477-8889
Practice Address - Street 1:555 10TH STREET NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5713
Practice Address - Country:US
Practice Address - Phone:404-477-8888
Practice Address - Fax:404-477-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5109Medicare PIN