Healthcare Provider Details

I. General information

NPI: 1316229602
Provider Name (Legal Business Name): SPORTS MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306A HIGH ST
GREENFIELD MA
01301-2611
US

IV. Provider business mailing address

306A HIGH ST
GREENFIELD MA
01301-2611
US

V. Phone/Fax

Practice location:
  • Phone: 413-773-3379
  • Fax: 713-772-2705
Mailing address:
  • Phone: 413-773-3379
  • Fax: 713-772-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2976
License Number StateMA

VIII. Authorized Official

Name: ELIZABETH DOLBY
Title or Position: OWNER
Credential:
Phone: 413-773-3379