Provider Demographics
NPI:1164613451
Name:SPINE & SPORT REHAB CENTER LLC
Entity Type:Organization
Organization Name:SPINE & SPORT REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVERONE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:508-285-1970
Mailing Address - Street 1:660 EAST ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-2951
Mailing Address - Country:US
Mailing Address - Phone:508-285-1970
Mailing Address - Fax:
Practice Address - Street 1:660 EAST ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048
Practice Address - Country:US
Practice Address - Phone:508-285-1970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6077380001Medicare NSC