Healthcare Provider Details

I. General information

NPI: 1225073521
Provider Name (Legal Business Name): SPORTS MED DENTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318 SAN JACINTO BLVD SUITE 108
DENTON TX
76205-7535
US

IV. Provider business mailing address

2318 SAN JACINTO BLVD SUITE 108
DENTON TX
76205-7535
US

V. Phone/Fax

Practice location:
  • Phone: 940-380-9111
  • Fax: 940-380-9112
Mailing address:
  • Phone: 940-380-9111
  • Fax: 940-380-9112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number652180000
License Number StateTX

VIII. Authorized Official

Name: KATHERINE DIERINGER
Title or Position: PRESIDENT
Credential:
Phone: 940-380-9111