Provider Demographics
NPI:1104190347
Name:SPINE AND SPORTS REHABILITATION
Entity Type:Organization
Organization Name:SPINE AND SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKSTILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-741-1206
Mailing Address - Street 1:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-0861
Mailing Address - Country:US
Mailing Address - Phone:870-741-1206
Mailing Address - Fax:870-743-5974
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3535
Practice Address - Country:US
Practice Address - Phone:870-741-1206
Practice Address - Fax:870-743-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty