Provider Demographics
NPI:1487198677
Name:SPINE DYNAMICS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SPINE DYNAMICS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANOS-TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-229-4500
Mailing Address - Street 1:4660 N BRETON CT SE STE 101
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-8438
Mailing Address - Country:US
Mailing Address - Phone:616-229-4500
Mailing Address - Fax:616-229-4500
Practice Address - Street 1:4660 N BRETON CT SE STE 101
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-8438
Practice Address - Country:US
Practice Address - Phone:616-229-4500
Practice Address - Fax:616-229-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006157225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501006157OtherSTATE LICENSE
MI1700832805Medicaid
MI5501006157OtherSTATE LICENSE