Basic Information
| Provider Information | |||||||||
| NPI: | 1558399121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORT AND SPINE PHYSICAL THERAPY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7340 S ALTON WAY | ||||||||
| Address2: | STE 11-D | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801122335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204931181 | ||||||||
| FaxNumber: | 7204931191 | ||||||||
| Practice Location | |||||||||
| Address1: | 7340 S ALTON WAY | ||||||||
| Address2: | STE 11-D | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801122335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204931181 | ||||||||
| FaxNumber: | 7204931191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDIN | ||||||||
| AuthorizedOfficialFirstName: | JOANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7204931181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 52923231 | 05 | CO | MEDICAID |