Healthcare Provider Details

I. General information

NPI: 1174823447
Provider Name (Legal Business Name): NEUROSPORT NYC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 8TH AVE SUITE 300
NEW YORK NY
10036-7000
US

IV. Provider business mailing address

1163 JOHNSON FERRY RD SUITE 100
MARIETTA GA
30068-2764
US

V. Phone/Fax

Practice location:
  • Phone: 212-245-1841
  • Fax: 212-245-1937
Mailing address:
  • Phone: 770-321-0155
  • Fax: 770-321-8426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MISS MORIAH MORGAN
Title or Position: REGIONAL OFFICE MANAGER
Credential:
Phone: 770-321-0155