Basic Information
| Provider Information | |||||||||
| NPI: | 1134493075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALISTS IN SPORTS AND ORTHOPEDIC REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 KENMOOR AVE SE STE 100 | ||||||||
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| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495462395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7381 W 133RD ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662134750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139041128 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2012 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEAVER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6163565000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.