Healthcare Provider Details

I. General information

NPI: 1396079224
Provider Name (Legal Business Name): SPORTS MEDICINE AND REHAB THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PINEVIEW DR
WAYCROSS GA
31501-5229
US

IV. Provider business mailing address

301 PINEVIEW DR
WAYCROSS GA
31501-5229
US

V. Phone/Fax

Practice location:
  • Phone: 912-285-0053
  • Fax: 912-283-9289
Mailing address:
  • Phone: 912-285-0053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CINDA BRYSON
Title or Position: BILLING MGR
Credential:
Phone: 912-285-0053