Provider Demographics
NPI:1942467501
Name:SPECTRUM SPINE AND SPORT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SPECTRUM SPINE AND SPORT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BILLYARD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-963-2400
Mailing Address - Street 1:3485 S MERCY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0429
Mailing Address - Country:US
Mailing Address - Phone:480-963-2400
Mailing Address - Fax:
Practice Address - Street 1:3485 S MERCY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0429
Practice Address - Country:US
Practice Address - Phone:480-963-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty