Healthcare Provider Details

I. General information

NPI: 1104000561
Provider Name (Legal Business Name): COMPETITIVE EDGE SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14160 JAMESTOWN RD
BREESE IL
62230
US

IV. Provider business mailing address

9431 HOLY CROSS LN
BREESE IL
62230-3510
US

V. Phone/Fax

Practice location:
  • Phone: 618-526-2603
  • Fax: 618-526-1435
Mailing address:
  • Phone: 618-526-2603
  • Fax: 618-526-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID L NEIGHBORS
Title or Position: PRESIDENT
Credential: MD
Phone: 618-526-2603