Healthcare Provider Details

I. General information

NPI: 1942238167
Provider Name (Legal Business Name): SPORT & SPINE CLINIC LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S.THIRD AVENUE SUITE B
EDGAR WI
54426
US

IV. Provider business mailing address

327 N 17TH AVE STE 7
WAUSAU WI
54401-4283
US

V. Phone/Fax

Practice location:
  • Phone: 715-352-2780
  • Fax: 715-352-2781
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD BINSTEIN
Title or Position: EVP
Credential:
Phone: 713-297-7000