Healthcare Provider Details

I. General information

NPI: 1982780813
Provider Name (Legal Business Name): SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S WISCONSIN DRIVE SUITE 3
JEFFERSON WI
53549
US

IV. Provider business mailing address

1300 W SAM HOUSTON PKWY S SUITE 300
HOUSTON TX
77042-2447
US

V. Phone/Fax

Practice location:
  • Phone: 920-699-4201
  • Fax: 920-699-4204
Mailing address:
  • Phone: 713-297-7000
  • Fax: 713-297-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: RICHARD BINSTEIN
Title or Position: VP,AUTHORIZED OFFICIAL
Credential: JD
Phone: 713-297-7000