Provider Demographics
NPI:1467510750
Name:SPORT & SPINE PHYSICAL THERAPY OF WINONA, INC
Entity Type:Organization
Organization Name:SPORT & SPINE PHYSICAL THERAPY OF WINONA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-474-6900
Mailing Address - Street 1:1512 SERVICE DR
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3803
Mailing Address - Country:US
Mailing Address - Phone:507-474-6900
Mailing Address - Fax:507-474-0502
Practice Address - Street 1:1512 SERVICE DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3803
Practice Address - Country:US
Practice Address - Phone:507-474-6900
Practice Address - Fax:507-474-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2012-01-23
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
MNC03769Medicare ID - Type Unspecified