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General NPI Number Information
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NPI Number | 1629419163
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Entity Type | Organization
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Legal Business Name | SPORTS MANAGEMENT INSTITUTE LLC
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Dates
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Enumeration Date | 07/12/2013
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Last Update Date | 07/12/2013
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Provider Practice Location Address
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Address Line | 14-20 WATSESSING AVE
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City | BLOOMFIELD
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State | NJ
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Zip | 07003-4611
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Country | US
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Telephone | 973-748-0067
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Fax |
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Provider Business Mailing Address
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Address Line | 14-20 WATSESSING AVE
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City | BLOOMFIELD
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State | NJ
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Zip | 07003-4611
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Country | US
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Telephone | 973-748-0067
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DINA DEGREGORIO
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Credential |
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Telephone | 973-748-0067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 0400560133
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License Number State | NJ
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