Provider Demographics
NPI:1982651618
Name:SPORTS AND SPINE PHYSICAL THERAPY NC INC
Entity Type:Organization
Organization Name:SPORTS AND SPINE PHYSICAL THERAPY NC INC
Other - Org Name:SPORTSPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:PT
Authorized Official - Phone:216-593-7070
Mailing Address - Street 1:3627 BEATTIES FORD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-3249
Mailing Address - Country:US
Mailing Address - Phone:704-394-6677
Mailing Address - Fax:
Practice Address - Street 1:3627 BEATTIES FORD RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-3249
Practice Address - Country:US
Practice Address - Phone:704-394-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4663Medicaid
NC7212192Medicaid
NC7212192Medicaid
SC8719Medicare PIN