Provider Demographics
NPI:1417137530
Name:SPECTRUM ORTHOPEDIC SPORT THERAPY
Entity Type:Organization
Organization Name:SPECTRUM ORTHOPEDIC SPORT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:PT CSCS
Authorized Official - Phone:650-654-1223
Mailing Address - Street 1:1140 LAUREL ST STE D
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5054
Mailing Address - Country:US
Mailing Address - Phone:650-654-1223
Mailing Address - Fax:650-654-1205
Practice Address - Street 1:1140 LAUREL ST STE D
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5054
Practice Address - Country:US
Practice Address - Phone:650-654-1223
Practice Address - Fax:650-654-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty