MEDICARE: SPORTS AND SPINE PHYSICAL THERAPY NC 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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982651618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS AND SPINE PHYSICAL THERAPY NC INC

Provider Business Mailing Address
First Line	:	3627 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3249
Country	:	US
Telephone Number	:	704-394-6677
Fax Number	:

Provider Business Practice Location Address
First Line	:	3627 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3249
Country	:	US
Telephone Number	:	704-394-6677
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LEON ANDERSON III
Credential	:	PT
Telephone Number	:	216-593-7070

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	11/10/2022

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