Healthcare Provider Details

I. General information

NPI: 1548920473
Provider Name (Legal Business Name): SPORT DEVELOPMENT SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/20/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BOYDEN ST
BOSTON MA
02124-3212
US

IV. Provider business mailing address

19 BOYDEN ST
BOSTON MA
02124-3212
US

V. Phone/Fax

Practice location:
  • Phone: 781-244-0894
  • Fax:
Mailing address:
  • Phone: 781-244-0894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. FLOYD ASHTON WILLIAMS-AGNEW
Title or Position: EXECUTIVE DIRECTOR/FOUNDER/MENTOR
Credential:
Phone: 781-244-0894