Organization
ORTHOPEDIC AND SPORTS ENHANCEMENT CENTER, LLC
Active
Other names
Sports Enhancement Center, LLC
Organization subpart
No
Provider details
NPI number
Authorized official
J. ANTHONY DUSTMAN (PRESIDENT)
(309) 663-9300
Entity
Organization
Contact information
Practice address
2406 E EMPIRE ST, BLOOMINGTON, IL 61704-3630
(309) 663-9300
(309) 661-1670
Mailing address
2406 E EMPIRE ST, BLOOMINGTON, IL 61704-3630
(309) 663-9300
(309) 661-1670
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
207X00000X
Orthopaedic Surgery Physician
—
—
Other
Enumeration date
10/03/2006
Last updated
09/12/2017
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