Provider Demographics
NPI:1568275907
Name:SPORT STATION ADAPTED EXERCISES CORP
Entity type:Organization
Organization Name:SPORT STATION ADAPTED EXERCISES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILA
Authorized Official - Middle Name:GONCALVES
Authorized Official - Last Name:DE ASSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-663-6580
Mailing Address - Street 1:696 WASHINGTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-2186
Mailing Address - Country:US
Mailing Address - Phone:508-663-6580
Mailing Address - Fax:
Practice Address - Street 1:696 WASHINGTON ST APT 1
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-2186
Practice Address - Country:US
Practice Address - Phone:508-663-6580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty