Provider Demographics
NPI:1548355183
Name:SPORTS HEALTHCARE CENTERS, INC.
Entity type:Organization
Organization Name:SPORTS HEALTHCARE CENTERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:ROTH
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-627-7532
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-4002
Mailing Address - Country:US
Mailing Address - Phone:940-627-7532
Mailing Address - Fax:940-627-7547
Practice Address - Street 1:2800 S FM 51
Practice Address - Street 2:STE B
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-4002
Practice Address - Country:US
Practice Address - Phone:940-627-7532
Practice Address - Fax:940-627-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX615540000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0217143-01Medicaid
TX0217143-01Medicaid