Provider Demographics
NPI:1609193911
Name:MIDWEST SPORT & SPINE REHABILITATION LLC
Entity Type:Organization
Organization Name:MIDWEST SPORT & SPINE REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:HARTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CERT MDT
Authorized Official - Phone:812-342-2411
Mailing Address - Street 1:4420 W JONATHAN MOORE PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-4685
Mailing Address - Country:US
Mailing Address - Phone:812-342-2411
Mailing Address - Fax:812-342-2413
Practice Address - Street 1:4420 W JONATHAN MOORE PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-4685
Practice Address - Country:US
Practice Address - Phone:812-342-2411
Practice Address - Fax:812-342-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008884A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy