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General NPI Number Information
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NPI Number | 1346439239
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Entity Type | Organization
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Legal Business Name | CENTER FOR SPINE & SPORTS REHABILITATION PC
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 02/22/2023
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Provider Practice Location Address
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Address Line | 3850 SHORE DR STE 305
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City | INDIANAPOLIS
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State | IN
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Zip | 46254-4693
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Country | US
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Telephone | 317-920-3220
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Fax | 317-920-3222
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Provider Business Mailing Address
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Address Line | 3850 SHORE DR STE 305
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City | INDIANAPOLIS
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State | IN
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Zip | 46254-4693
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Country | US
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Telephone | 317-920-3220
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Fax | 317-920-3221
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THELMA LYNETTE GREEN-MACK
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Credential | MD
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Telephone | 317-920-3220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 01037601B
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License Number State | IN
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