Provider Demographics
NPI:1730855016
Name:BLACK WATCH SPORTS PERFORMANCE
Entity type:Organization
Organization Name:BLACK WATCH SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:229-402-3338
Mailing Address - Street 1:157 RESOURCE CENTER PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-8135
Mailing Address - Country:US
Mailing Address - Phone:229-402-3338
Mailing Address - Fax:205-453-4603
Practice Address - Street 1:157 RESOURCE CENTER PKWY STE 107
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-8135
Practice Address - Country:US
Practice Address - Phone:229-402-3338
Practice Address - Fax:205-453-4603
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK WATCH SPORTS PERFORMANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1255980181OtherBLUE CROSS BLUE SHIELD