Healthcare Provider Details

I. General information

NPI: 1154519064
Provider Name (Legal Business Name): ORTHOPEDIC SPINE AND SPORTS THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 07/21/2022
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54945 MOUND RD
SHELBY TOWNSHIP MI
48316-6028
US

IV. Provider business mailing address

54945 MOUND RD
SHELBY TOWNSHIP MI
48316-6028
US

V. Phone/Fax

Practice location:
  • Phone: 586-992-1500
  • Fax: 586-992-8050
Mailing address:
  • Phone: 586-992-1500
  • Fax: 586-992-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: KATHY CLARK
Title or Position: CREDENTIALING
Credential:
Phone: 586-992-1500