Provider Demographics
NPI:1407030497
Name:SPINE & ORTHOPAEDIC PHYSICAL THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:SPINE & ORTHOPAEDIC PHYSICAL THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-540-8708
Mailing Address - Street 1:16601 N 40TH ST
Mailing Address - Street 2:SUITE 229
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3345
Mailing Address - Country:US
Mailing Address - Phone:602-540-8708
Mailing Address - Fax:
Practice Address - Street 1:16601 N 40TH ST
Practice Address - Street 2:SUITE 229
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3345
Practice Address - Country:US
Practice Address - Phone:602-540-8708
Practice Address - Fax:602-643-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy