Provider Demographics
NPI:1629294764
Name:SPORT AND SPINE PHYSICAL THERAPY CENTER INC
Entity Type:Organization
Organization Name:SPORT AND SPINE PHYSICAL THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DONOFRIO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-543-3902
Mailing Address - Street 1:595 WILDWOOD RD WEST
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1125
Mailing Address - Country:US
Mailing Address - Phone:201-543-3902
Mailing Address - Fax:201-750-2949
Practice Address - Street 1:103 N SUMMITT ST
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670
Practice Address - Country:US
Practice Address - Phone:201-816-0042
Practice Address - Fax:201-816-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA08961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ095675Medicare PIN