Basic Information
| Provider Information | |||||||||
| NPI: | 1376745091 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE SPORTS & INDUSTRIAL REHABILITATION OF LIGONIER, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656560 | ||||||||
| FaxNumber: | 2193656561 | ||||||||
| Practice Location | |||||||||
| Address1: | 157 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | LIGONIER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467679537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2608949909 | ||||||||
| FaxNumber: | 2608949913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | IMBODY | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2608949909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.