Provider Demographics
NPI:1366635559
Name:SPEARS, SHADRACK E (PTA)
Entity Type:Individual
Prefix:
First Name:SHADRACK
Middle Name:E
Last Name:SPEARS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4126 LUM ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-6526
Mailing Address - Country:US
Mailing Address - Phone:269-323-4300
Mailing Address - Fax:269-323-4449
Practice Address - Street 1:1423 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5351
Practice Address - Country:US
Practice Address - Phone:269-323-4300
Practice Address - Fax:269-323-4449
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant