Provider Demographics
NPI:1396794970
Name:SPORT REHAB, INC.
Entity type:Organization
Organization Name:SPORT REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIKAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PORTELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT/ATC
Authorized Official - Phone:573-368-0999
Mailing Address - Street 1:906 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3350
Mailing Address - Country:US
Mailing Address - Phone:573-368-0999
Mailing Address - Fax:573-368-2777
Practice Address - Street 1:906 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3350
Practice Address - Country:US
Practice Address - Phone:573-368-0999
Practice Address - Fax:573-368-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2010-08-09
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
990001517Medicare ID - Type Unspecified