Healthcare Provider Details

I. General information

NPI: 1730855016
Provider Name (Legal Business Name): BLACK WATCH SPORTS PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 RESOURCE CENTER PKWY STE 107
BIRMINGHAM AL
35242-8135
US

IV. Provider business mailing address

157 RESOURCE CENTER PKWY STE 107
BIRMINGHAM AL
35242-8135
US

V. Phone/Fax

Practice location:
  • Phone: 229-402-3338
  • Fax: 205-453-4603
Mailing address:
  • Phone: 229-402-3338
  • Fax: 205-453-4603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELLEY ANNE ANDERSON
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 229-402-3338