Healthcare Provider Details

I. General information

NPI: 1003900820
Provider Name (Legal Business Name): ORTHOPEDIC AND SPORTS ENHANCEMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-9300
  • Fax: 309-661-1670
Mailing address:
  • Phone: 309-663-9300
  • Fax: 309-661-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: J. ANTHONY DUSTMAN
Title or Position: PRESIDENT
Credential:
Phone: 309-663-9300