Provider Demographics
NPI:1043266646
Name:ORTHOPEDIC & SPINE PHYSICAL THERAPY OF L/A INC.
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE PHYSICAL THERAPY OF L/A INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:TEIXEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MOMT,OCS
Authorized Official - Phone:207-777-3002
Mailing Address - Street 1:581 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5945
Mailing Address - Country:US
Mailing Address - Phone:207-777-3002
Mailing Address - Fax:207-777-3004
Practice Address - Street 1:581 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5945
Practice Address - Country:US
Practice Address - Phone:207-777-3002
Practice Address - Fax:207-777-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty