MEDICARE: SPINE & SPORT PHYSICAL THERAPY SERVICES 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650D157110	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1053324749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE & SPORT PHYSICAL THERAPY SERVICES INC.

Provider Business Mailing Address
First Line	:	2816 EAST BELTLINE LANE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9432
Country	:	US
Telephone Number	:	616-361-1210
Fax Number	:	616-361-8662

Provider Business Practice Location Address
First Line	:	2816 EAST BELTLINE LANE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9432
Country	:	US
Telephone Number	:	616-361-1210
Fax Number	:	616-361-8662

Authorized Official
Title or Position	:	OWNER PHYSICAL THERAPIST
Name	:	MRS. SHIRLEY A KLEIMAN
Credential	:	PT DPT OCS CERT MDT
Telephone Number	:	616-361-1210

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	12/13/2013

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Directions to “SPINE & SPORT PHYSICAL THERAPY SERVICES INC. ” Practice Location

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