Healthcare Provider Details

I. General information

NPI: 1629419163
Provider Name (Legal Business Name): SPORTS MANAGEMENT INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14-20 WATSESSING AVE
BLOOMFIELD NJ
07003-4611
US

IV. Provider business mailing address

14-20 WATSESSING AVE
BLOOMFIELD NJ
07003-4611
US

V. Phone/Fax

Practice location:
  • Phone: 973-748-0067
  • Fax:
Mailing address:
  • Phone: 973-748-0067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0400560133
License Number StateNJ

VIII. Authorized Official

Name: DINA DEGREGORIO
Title or Position: MANAGER
Credential:
Phone: 973-748-0067