Healthcare Provider Details

I. General information

NPI: 1528147907
Provider Name (Legal Business Name): SPORTS MEDICINE AND REHAB THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 PIONEER LN SUITE D
BISHOP CA
93514-2563
US

IV. Provider business mailing address

152 PIONEER LN SUITE D
BISHOP CA
93514-2563
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-8220
  • Fax: 760-873-4443
Mailing address:
  • Phone: 760-873-8220
  • Fax: 760-873-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00PT78460
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number0PT253460
License Number StateCA

VIII. Authorized Official

Name: MS. PATRICIA L. GARDNER
Title or Position: PRESIDENT
Credential: P.T.
Phone: 760-873-8220