Provider Demographics
NPI:1184812612
Name:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:713-297-7000
Mailing Address - Street 1:1300 W SAM HOUSTON PKWY S
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2447
Mailing Address - Country:US
Mailing Address - Phone:713-297-7000
Mailing Address - Fax:713-297-7090
Practice Address - Street 1:119 HENRY STREET
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534
Practice Address - Country:US
Practice Address - Phone:608-884-8514
Practice Address - Fax:608-884-8524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526592Medicare Oscar/Certification