Organization
SPORT IS RELIGION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. BREANNA N EDWARDS (DIRECTOR OF OPERATIONS)
(682) 785-7348
Entity
Organization
Contact information
Practice address
8641 LAS VEGAS CT APT 2722, FORT WORTH, TX 76116-0044
(682) 785-7348
Mailing address
8641 LAS VEGAS CT APT 2722, FORT WORTH, TX 76116-0044
(682) 785-7348
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Enumeration date
04/09/2020
Last updated
04/09/2020
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