Healthcare Provider Details

I. General information

NPI: 1790873883
Provider Name (Legal Business Name): SPORTS MEDICINE AND TRAINING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WATSON PLAZA
ST. LOUIS MO
63126-1962
US

IV. Provider business mailing address

119 WATSON PLAZA
ST. LOUIS MO
63126-1962
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-3787
  • Fax: 314-961-0974
Mailing address:
  • Phone: 314-961-3787
  • Fax: 314-961-0974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: R. SCOTT VAN NEST
Title or Position: OWNER
Credential: P.T.
Phone: 314-961-3787