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General NPI Number Information
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NPI Number | 1902089204
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Entity Type | Organization
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Legal Business Name | THE S.P.O.R.T. INSTITUTE MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 12/10/2007
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Last Update Date | 08/11/2011
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Provider Practice Location Address
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Address Line | 7525 LINDA VISTA RD. SUITE C
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City | SAN DIEGO
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State | CA
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Zip | 92111
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Country | US
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Telephone | 858-650-3030
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Fax | 858-650-3033
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Provider Business Mailing Address
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Address Line | 7525 LINDA VISTA RD. SUITE C
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City | SAN DIEGO
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State | CA
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Zip | 92111
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Country | US
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Telephone | 858-650-3030
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Fax | 858-650-3033
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILLIAM JOSEPH PREVITE
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Credential | D.O.
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Telephone | 858-650-3030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 20A5466
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License Number State | CA
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