MEDICARE: SPINE & SPORT PHYSICAL THERAPY, PLLC

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	2251X0800X	Orthopedic Physical Therapist	2305204141	VA

General Provider Information

NPI Number	:	1710135546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE & SPORT PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1119
Second Line	:
City	:	STEPHENS CITY
State	:	VA
Zip	:	22655-1119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	640 WARRIOR DR
Second Line	:	SUITE 115
City	:	STEPHENS CITY
State	:	VA
Zip	:	22655-4076
Country	:	US
Telephone Number	:	540-868-9599
Fax Number	:

Authorized Official
Title or Position	:	OWNER, DIRECTOR, PHYSICAL THERAPIST
Name	:	DR. KEVIN DAVID FORRER
Credential	:	PT, DPT
Telephone Number	:	610-507-7878

Provider Enumeration Date	:	09/04/2008
Last Update Date	:	09/04/2008

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