MEDICARE: ORTHOPEDIC & SPINE PHYSICAL THERAPY OF L/A INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT2321	ME

General Provider Information

NPI Number	:	1043266646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPEDIC & SPINE PHYSICAL THERAPY OF L/A INC.

Provider Business Mailing Address
First Line	:	581 MAIN ST
Second Line	:	SUITE 1
City	:	LEWISTON
State	:	ME
Zip	:	04240-5945
Country	:	US
Telephone Number	:	207-777-3002
Fax Number	:	207-777-3004

Provider Business Practice Location Address
First Line	:	581 MAIN ST
Second Line	:	SUITE 1
City	:	LEWISTON
State	:	ME
Zip	:	04240-5945
Country	:	US
Telephone Number	:	207-777-3002
Fax Number	:	207-777-3004

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/ OWNER
Name	:	MR. SHAN MARTIN TEIXEIRA
Credential	:	PT, MOMT,OCS
Telephone Number	:	207-777-3002

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	12/09/2010

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