Provider Demographics
NPI:1225040694
Name:SHORELINE SPORT & SPINE PC
Entity Type:Organization
Organization Name:SHORELINE SPORT & SPINE PC
Other - Org Name:I'MOVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:VANANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, SCS, FAFS
Authorized Official - Phone:616-847-1280
Mailing Address - Street 1:18000 COVE STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:616-847-1290
Practice Address - Street 1:18000 COVE STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456
Practice Address - Country:US
Practice Address - Phone:616-847-1280
Practice Address - Fax:616-847-1290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P14760Medicare PIN