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General NPI Number Information
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NPI Number | 1063009272
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Entity Type | Organization
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Legal Business Name | SPORTS AND REHABILITATION CENTER OF WYOMING LLC
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Dates
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Enumeration Date | 12/22/2020
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Last Update Date | 05/23/2021
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Provider Practice Location Address
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Address Line | 625 E BROADWAY AVE
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City | JACKSON
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State | WY
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Zip | 83001-8642
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Country | US
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Telephone | 307-920-1688
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Fax |
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Provider Business Mailing Address
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Address Line | 522 N SWEETZER AVE APT 5
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City | LOS ANGELES
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State | CA
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Zip | 90048-2659
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Country | US
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Telephone | 310-307-9670
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | AUSTIN HAMMESFAHR
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Credential |
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Telephone | 310-307-9670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225400000X
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Taxonomy Name | Rehabilitation Practitioner
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License Number |
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License Number State |
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