Provider Demographics
NPI:1902089204
Name:THE S.P.O.R.T. INSTITUTE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:THE S.P.O.R.T. INSTITUTE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PREVITE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:858-650-3030
Mailing Address - Street 1:7525 LINDA VISTA RD.
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111
Mailing Address - Country:US
Mailing Address - Phone:858-650-3030
Mailing Address - Fax:858-650-3033
Practice Address - Street 1:7525 LINDA VISTA RD.
Practice Address - Street 2:SUITE C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:858-650-3030
Practice Address - Fax:858-650-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5466174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14295Medicare PIN