Provider Demographics
NPI:1346279643
Name:SPORT & SPINE CLINIC LP
Entity Type:Organization
Organization Name:SPORT & SPINE CLINIC LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP,AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BINSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:713-297-7000
Mailing Address - Street 1:327 N 17TH AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4107 BARBICAN AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4143
Practice Address - Country:US
Practice Address - Phone:715-359-8465
Practice Address - Fax:715-359-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526555Medicare Oscar/Certification