=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780020396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORT & SPINE CLINIC L.P.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2013
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213016 LEGION ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-687-2214
-----------------------------------------------------
Fax | 715-687-4716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 327 N 17TH AVE STE 7
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54401-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | RICHARD BINSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-297-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------