Healthcare Provider Details

I. General information

NPI: 1033316039
Provider Name (Legal Business Name): SPORTS AND SPINE THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7830 N CENTRAL EXPY
DALLAS TX
75206-1902
US

IV. Provider business mailing address

7830 N CENTRAL EXPY
DALLAS TX
75206-1902
US

V. Phone/Fax

Practice location:
  • Phone: 214-739-2225
  • Fax: 214-739-2228
Mailing address:
  • Phone: 214-739-2225
  • Fax: 214-739-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: ROBERT TODD PETERSEN
Title or Position: PROPRIETOR
Credential: DC, OPA-C, CCSP, ATC
Phone: 214-739-2225