Provider Demographics
NPI:1679522866
Name:SPECTRA SPORTS MEDICINE & PHYSICAL THERAPY, LP
Entity Type:Organization
Organization Name:SPECTRA SPORTS MEDICINE & PHYSICAL THERAPY, LP
Other - Org Name:FYZICAL THERAPY & BALANCE CENTERS LUBBOCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:806-785-7900
Mailing Address - Street 1:6801 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-6109
Mailing Address - Country:US
Mailing Address - Phone:806-785-7900
Mailing Address - Fax:806-785-7909
Practice Address - Street 1:6801 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-6109
Practice Address - Country:US
Practice Address - Phone:806-785-7900
Practice Address - Fax:806-785-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2023-07-28
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
TX0072KXOtherBLUE CROSS BLUE SHIELD
TX7970614OtherAETNA
TX00806WMedicare ID - Type UnspecifiedMEDICARE PART B
TXDC0363Medicare ID - Type UnspecifiedRAILROAD MEDICARE/PALMETT