Healthcare Provider Details

I. General information

NPI: 1164894812
Provider Name (Legal Business Name): SPORT & SPINE CLINIC LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 S CHERRY AVE SUITE 2
MARSHFIELD WI
54449-4276
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 715-652-3470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

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