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General NPI Number Information
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NPI Number | 1417137530
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Entity Type | Organization
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Legal Business Name | SPECTRUM ORTHOPEDIC SPORT THERAPY
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Dates
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Enumeration Date | 11/06/2007
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 1140 LAUREL ST STE D
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City | SAN CARLOS
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State | CA
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Zip | 94070-5054
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Country | US
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Telephone | 650-654-1223
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Fax | 650-654-1205
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Provider Business Mailing Address
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Address Line | 1140 LAUREL ST STE D
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City | SAN CARLOS
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State | CA
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Zip | 94070-5054
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Country | US
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Telephone | 650-654-1223
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Fax | 650-654-1205
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Authorized Official
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Title or Position | PHYSICAL THERAPIST OWNER
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Name | MR. KENNETH WILLIAM BURNS
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Credential | PT CSCS
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Telephone | 650-654-1223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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