Provider Demographics
NPI:1841717410
Name:PHYSIO SPORT & SPINE LLC
Entity type:Organization
Organization Name:PHYSIO SPORT & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:CHILDS
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:307-421-4094
Mailing Address - Street 1:4012 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-5560
Mailing Address - Country:US
Mailing Address - Phone:307-421-4094
Mailing Address - Fax:
Practice Address - Street 1:433 E 19TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4643
Practice Address - Country:US
Practice Address - Phone:307-421-4094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY09842251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty