Healthcare Provider Details

I. General information

NPI: 1720075450
Provider Name (Legal Business Name): SUPERIOR SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 TOWERVIEW COURT
CARY NC
27513
US

IV. Provider business mailing address

PO BOX 880
CARY NC
27512-0880
US

V. Phone/Fax

Practice location:
  • Phone: 919-459-4135
  • Fax: 919-882-1247
Mailing address:
  • Phone: 919-459-4135
  • Fax: 919-882-1247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number000878433
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number00811
License Number StateNC

VIII. Authorized Official

Name: MR. GREGORY C FEDERICO
Title or Position: MANAGER
Credential: ORTHOTIC FITTER
Phone: 919-459-4135