Provider Demographics
NPI:1407904113
Name:SPINE SPORTS AND INDUSTRIAL REHABILITATION OF ELKHART
Entity Type:Organization
Organization Name:SPINE SPORTS AND INDUSTRIAL REHABILITATION OF ELKHART
Other - Org Name:SSIR OF ELKHART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SZYNAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-266-7747
Mailing Address - Street 1:1615 WINSTED DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4696
Mailing Address - Country:US
Mailing Address - Phone:574-534-4648
Mailing Address - Fax:
Practice Address - Street 1:1510 OSOLO RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4122
Practice Address - Country:US
Practice Address - Phone:574-534-4648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN250610Medicare PIN