Healthcare Provider Details

I. General information

NPI: 1184652737
Provider Name (Legal Business Name): SPORTS MEDICINE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 KAPALAMA RD. SUITE B.
PASS CHRISTIAN MS
39571
US

IV. Provider business mailing address

17000 KAPALAMA RD. SUITE B
PASS CHRISTIAN MS
39571
US

V. Phone/Fax

Practice location:
  • Phone: 228-255-6868
  • Fax: 228-255-6860
Mailing address:
  • Phone: 228-255-6868
  • Fax: 228-255-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK A. SCHMIDT
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 228-255-6868