Healthcare Provider Details

I. General information

NPI: 1033142013
Provider Name (Legal Business Name): SPINE AND SPORT PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32261 CAMINO CAPISTRANO SUITE D101
SAN JUAN CAPISTRANO CA
92675-3746
US

IV. Provider business mailing address

32261 CAMINO CAPISTRANO SUITE D101
SAN JUAN CAPISTRANO CA
92675-3746
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-2155
  • Fax: 949-429-2151
Mailing address:
  • Phone: 949-429-2155
  • Fax: 949-429-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCA27078
License Number StateCA

VIII. Authorized Official

Name: PAUL BATCHELOR
Title or Position: OWNER, PRESIDENT
Credential:
Phone: 949-429-2155