Provider Demographics
NPI:1053324749
Name:SPINE & SPORT PHYSICAL THERAPY SERVICES INC.
Entity Type:Organization
Organization Name:SPINE & SPORT PHYSICAL THERAPY SERVICES INC.
Other - Org Name:SPINE & SPORT BIOMECHANICAL REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLEIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT OCS CERT MDT
Authorized Official - Phone:616-361-1210
Mailing Address - Street 1:2816 EAST BELTLINE LANE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9432
Mailing Address - Country:US
Mailing Address - Phone:616-361-1210
Mailing Address - Fax:616-361-8662
Practice Address - Street 1:2816 EAST BELTLINE LANE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9432
Practice Address - Country:US
Practice Address - Phone:616-361-1210
Practice Address - Fax:616-361-8662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650D157110OtherBCBS
MI650D157110OtherBCBS