Provider Demographics
NPI:1538553995
Name:SPORT-SOCIAL
Entity type:Organization
Organization Name:SPORT-SOCIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-505-2864
Mailing Address - Street 1:7055 WINDY ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-4029
Mailing Address - Country:US
Mailing Address - Phone:702-485-5515
Mailing Address - Fax:702-534-4840
Practice Address - Street 1:7055 WINDY ST STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-4029
Practice Address - Country:US
Practice Address - Phone:702-485-5515
Practice Address - Fax:702-534-4840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Single Specialty