MEDICARE: SPORTSRX LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1548776362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTSRX LLC

Provider Business Mailing Address
First Line	:	12409 WYNMEADE PL
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-1630
Country	:	US
Telephone Number	:	502-303-0919
Fax Number	:	772-872-5889

Provider Business Practice Location Address
First Line	:	12409 WYNMEADE PL
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-1630
Country	:	US
Telephone Number	:	502-303-0919
Fax Number	:	772-872-5889

Authorized Official
Title or Position	:	OWNER
Name	:	JIMMY BRANNON
Credential	:
Telephone Number	:	502-890-3198

Provider Enumeration Date	:	12/15/2017
Last Update Date	:	12/15/2017

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