MEDICARE: ALPHA SPORTS MCKINNEY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	133VN1501X	Sports Dietetics Nutrition Registered Dietitian
2	2251X0800X	Orthopedic Physical Therapist
3	225700000X	Massage Therapist
4	103TE1100X	Exercise & Sports Psychologist
5	111NS0005X	Sports Physician Chiropractor
6	2251S0007X	Sports Physical Therapist

General Provider Information

NPI Number	:	1255117925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA SPORTS MCKINNEY, LLC

Provider Business Mailing Address
First Line	:	4438 SH 6 S
Second Line	:	#104
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845
Country	:	US
Telephone Number	:	979-398-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 RIDGE RD S
Second Line	:	SUITE 111
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845
Country	:	US
Telephone Number	:	469-608-0386
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BENJAMIN BUMGUARDNER
Credential	:	DC
Telephone Number	:	325-660-3266

Provider Enumeration Date	:	09/07/2023
Last Update Date	:	09/07/2023

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