Provider Demographics
NPI:1699895490
Name:DADEVILLE SPORTS MEDICINE & PHYSICAL THERAPY
Entity type:Organization
Organization Name:DADEVILLE SPORTS MEDICINE & PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SYMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-329-8180
Mailing Address - Street 1:1120 AIRPORT DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALEXANDER CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35010-3436
Mailing Address - Country:US
Mailing Address - Phone:256-329-8180
Mailing Address - Fax:256-329-8116
Practice Address - Street 1:1120 AIRPORT DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3436
Practice Address - Country:US
Practice Address - Phone:256-329-8180
Practice Address - Fax:256-329-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1013261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS66770Medicare UPIN