Healthcare Provider Details

I. General information

NPI: 1528995487
Provider Name (Legal Business Name): SPORTS OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 ELLABOND ST
SNEADS FERRY NC
28460-1412
US

IV. Provider business mailing address

704 ELLABOND ST
SNEADS FERRY NC
28460-1412
US

V. Phone/Fax

Practice location:
  • Phone: 631-774-3055
  • Fax:
Mailing address:
  • Phone: 631-774-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ALI ADLAH
Title or Position: OWNER
Credential: OTR/L
Phone: 631-774-3055