Healthcare Provider Details

I. General information

NPI: 1861800070
Provider Name (Legal Business Name): SPORT AND SPINE REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N KEENE ST STE 102
COLUMBIA MO
65201-7193
US

IV. Provider business mailing address

303 N KEENE ST STE 102
COLUMBIA MO
65201-7193
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-0225
  • Fax:
Mailing address:
  • Phone: 573-443-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2011030640
License Number StateMO

VIII. Authorized Official

Name: MARTY MORRIS
Title or Position: MANAGER
Credential:
Phone: 573-443-0225