Healthcare Provider Details

I. General information

NPI: 1841717410
Provider Name (Legal Business Name): PHYSIO SPORT & SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 E 19TH ST
CHEYENNE WY
82001-4643
US

IV. Provider business mailing address

4012 ROGERS AVE
CHEYENNE WY
82009-5560
US

V. Phone/Fax

Practice location:
  • Phone: 307-421-4094
  • Fax:
Mailing address:
  • Phone: 307-421-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0984
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number0984
License Number StateWY

VIII. Authorized Official

Name: DR. JAMIE CHILDS EVERETT
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT, DPT
Phone: 307-421-4094