Healthcare Provider Details

I. General information

NPI: 1205642121
Provider Name (Legal Business Name): ATHLETE RESTORATION LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6155 SPORTS VILLAGE RD STE 400
FRISCO TX
75033-3578
US

IV. Provider business mailing address

6155 SPORTS VILLAGE RD STE 400
FRISCO TX
75033-3578
US

V. Phone/Fax

Practice location:
  • Phone: 877-735-2201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JARED GILLESPIE
Title or Position: CO-OWNER
Credential: PT
Phone: 913-620-0040