Provider Demographics
NPI:1710079454
Name:SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SPARTA ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:C
Authorized Official - Last Name:THEURET
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:973-726-0111
Mailing Address - Street 1:57 SPARTA AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1822
Mailing Address - Country:US
Mailing Address - Phone:973-726-0111
Mailing Address - Fax:973-726-0399
Practice Address - Street 1:57 SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1822
Practice Address - Country:US
Practice Address - Phone:973-726-0111
Practice Address - Fax:973-726-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01006600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ611366300OtherDEPARTMENT OF LABOR
NJ=========OtherHORIZON BCBS
NJ611366300OtherDEPARTMENT OF LABOR