Healthcare Provider Details

I. General information

NPI: 1700188463
Provider Name (Legal Business Name): SOUTHERN OHIO SPORTS MEDICINE AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 RARDEN RD
PEEBLES OH
45660-1049
US

IV. Provider business mailing address

118 RARDEN RD
PEEBLES OH
45660-1049
US

V. Phone/Fax

Practice location:
  • Phone: 937-587-9422
  • Fax: 937-587-9522
Mailing address:
  • Phone: 937-587-9422
  • Fax: 937-587-9522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT 5740
License Number StateOH

VIII. Authorized Official

Name: MRS. MELISSA MAE WADDELL
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 937-587-9422