Healthcare Provider Details

I. General information

NPI: 1053324749
Provider Name (Legal Business Name): SPINE & SPORT PHYSICAL THERAPY SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2816 EAST BELTLINE LANE NE
GRAND RAPIDS MI
49525-9432
US

IV. Provider business mailing address

2816 EAST BELTLINE LANE NE
GRAND RAPIDS MI
49525-9432
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-1210
  • Fax: 616-361-8662
Mailing address:
  • Phone: 616-361-1210
  • Fax: 616-361-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHIRLEY A KLEIMAN
Title or Position: OWNER PHYSICAL THERAPIST
Credential: PT DPT OCS CERT MDT
Phone: 616-361-1210