Provider Demographics
NPI:1376745091
Name:SPINE SPORTS & INDUSTRIAL REHABILITATION OF LIGONIER, INC.
Entity Type:Organization
Organization Name:SPINE SPORTS & INDUSTRIAL REHABILITATION OF LIGONIER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:IMBODY
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:260-894-9909
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6560
Mailing Address - Fax:219-365-6561
Practice Address - Street 1:157 RIVER RD
Practice Address - Street 2:
Practice Address - City:LIGONIER
Practice Address - State:IN
Practice Address - Zip Code:46767-9537
Practice Address - Country:US
Practice Address - Phone:260-894-9909
Practice Address - Fax:260-894-9913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN259040Medicare PIN