Provider Demographics
NPI:1639113251
Name:SPORT AND SPINE PHYSICAL THERAPY AND REHAB SPECIALISTS
Entity Type:Organization
Organization Name:SPORT AND SPINE PHYSICAL THERAPY AND REHAB SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRIAND
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT, ATC
Authorized Official - Phone:877-552-2996
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:5245 JACKSON RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103
Practice Address - Country:US
Practice Address - Phone:734-327-4716
Practice Address - Fax:734-327-4748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2011-08-22
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
DR5592Medicare PIN
MI0P30720Medicare ID - Type Unspecified
MI5696860001Medicare NSC