Healthcare Provider Details

I. General information

NPI: 1972856524
Provider Name (Legal Business Name): THE PT CENTER FOR SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 W MARKET ST STE 300
FAIRLAWN OH
44333-4209
US

IV. Provider business mailing address

2660 W MARKET ST STE 300
FAIRLAWN OH
44333-4209
US

V. Phone/Fax

Practice location:
  • Phone: 330-869-2635
  • Fax: 330-869-8315
Mailing address:
  • Phone: 330-869-2635
  • Fax: 330-869-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003740
License Number StateOH

VIII. Authorized Official

Name: MRS. TINA OUTWATER
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-869-2635