Healthcare Provider Details

I. General information

NPI: 1467546531
Provider Name (Legal Business Name): SPORT & SPINE PHYSICAL THERAPY OF WINONA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 SERVICE DR
WINONA MN
55987-3803
US

IV. Provider business mailing address

1512 SERVICE DR
WINONA MN
55987-3803
US

V. Phone/Fax

Practice location:
  • Phone: 507-474-6900
  • Fax: 507-474-0502
Mailing address:
  • Phone: 507-474-6900
  • Fax: 507-474-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LORI A OBRIEN
Title or Position: VP OF ADMINISTRATION
Credential:
Phone: 507-474-6900