Provider Demographics
NPI:1922186956
Name:SPORTS & ORTHOPEDIC PHYSICAL THERAPY CLINIC INC
Entity Type:Organization
Organization Name:SPORTS & ORTHOPEDIC PHYSICAL THERAPY CLINIC INC
Other - Org Name:WINSTEAD & WINTERS PHYSICAL THERAPY CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:559-432-0524
Mailing Address - Street 1:6335 N. FRESNO STREET
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710
Mailing Address - Country:US
Mailing Address - Phone:559-432-0524
Mailing Address - Fax:559-449-8646
Practice Address - Street 1:6335 N FRESNO STREET
Practice Address - Street 2:SUITE 108
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-432-0524
Practice Address - Fax:559-449-8646
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS & ORTHOPEDIC PHYSICAL THERAPY CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29992261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GE882AMedicare PIN