Provider Demographics
NPI:1083077499
Name:SPINE & SPORTS PHYSICAL THERAPY & DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:SPINE & SPORTS PHYSICAL THERAPY & DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:410-625-5050
Mailing Address - Street 1:1406B CRAIN HWY S
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4099
Mailing Address - Country:US
Mailing Address - Phone:410-625-5050
Mailing Address - Fax:410-766-1404
Practice Address - Street 1:1406B CRAIN HWY S
Practice Address - Street 2:SUITE 107
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4099
Practice Address - Country:US
Practice Address - Phone:410-625-5050
Practice Address - Fax:410-766-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-02
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty