Provider Demographics
NPI:1134259252
Name:SPORTS THERAPY & REHABILITATION CENTER, INC.
Entity type:Organization
Organization Name:SPORTS THERAPY & REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:978-741-0880
Mailing Address - Street 1:84 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2727
Mailing Address - Country:US
Mailing Address - Phone:978-741-0880
Mailing Address - Fax:
Practice Address - Street 1:84 HIGHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2727
Practice Address - Country:US
Practice Address - Phone:978-741-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA135261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0368989Medicaid
MAY61051OtherBLUE CROSS / BLUE SHIELD
MAAA68907OtherHARVARD PILGRIM
MAPT0312Medicare PIN