Healthcare Provider Details

I. General information

NPI: 1265619381
Provider Name (Legal Business Name): SPORTS PLUS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S MAIN ST
NEVADA MO
64772-3363
US

IV. Provider business mailing address

127 S MAIN ST
NEVADA MO
64772-3363
US

V. Phone/Fax

Practice location:
  • Phone: 417-667-4620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberR1J25
License Number StateMO

VIII. Authorized Official

Name: MRS. DEBRA COMPTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 417-667-4620