Healthcare Provider Details

I. General information

NPI: 1376690214
Provider Name (Legal Business Name): SMART SPORTS MEDICINE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5307 YELLOWSTONE RD
CHEYENNE WY
82009-4736
US

IV. Provider business mailing address

PO BOX 20168
CHEYENNE WY
82003-7004
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-7677
  • Fax: 307-778-8292
Mailing address:
  • Phone: 307-632-7677
  • Fax: 307-778-8292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. VINCENT J ROSS
Title or Position: OWNER
Credential:
Phone: 307-632-7677