Provider Demographics
NPI:1174683858
Name:SPINE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SPINE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:ST JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:269-492-6575
Mailing Address - Street 1:7125 STADIUM DRIVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-492-6575
Mailing Address - Fax:269-492-6577
Practice Address - Street 1:7125 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-492-6575
Practice Address - Fax:269-492-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2016-01-13
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
MI0P40960Medicare PIN