MEDICARE: SPORT & SPINE CLINIC LP

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	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1528004553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORT & SPINE CLINIC LP

Provider Business Mailing Address
First Line	:	327 N 17TH AVE STE 7
Second Line	:
City	:	WAUSAU
State	:	WI
Zip	:	54401-4283
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 WESTERN AVE
Second Line	:	SUITE B
City	:	MOSINEE
State	:	WI
Zip	:	54455-1529
Country	:	US
Telephone Number	:	715-693-7727
Fax Number	:	715-693-7171

Authorized Official
Title or Position	:	VP/AUTHORIZED OFFICIAL
Name	:	RICHARD BINSTEIN
Credential	:	JD
Telephone Number	:	713-297-7000

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	01/17/2022

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