MEDICARE: SPINE AND SPORT PHYSICAL THERAPY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	CA27078	CA

General Provider Information

NPI Number	:	1033142013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND SPORT PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	32261 CAMINO CAPISTRANO
Second Line	:	SUITE D101
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3746
Country	:	US
Telephone Number	:	949-429-2155
Fax Number	:	949-429-2151

Provider Business Practice Location Address
First Line	:	32261 CAMINO CAPISTRANO
Second Line	:	SUITE D101
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3746
Country	:	US
Telephone Number	:	949-429-2155
Fax Number	:	949-429-2151

Authorized Official
Title or Position	:	OWNER, PRESIDENT
Name	:	PAUL BATCHELOR
Credential	:
Telephone Number	:	949-429-2155

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	10/04/2013

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