Provider Demographics
NPI:1679906176
Name:SPINE & SPORTS REHABILITATION INSTITUTE
Entity type:Organization
Organization Name:SPINE & SPORTS REHABILITATION INSTITUTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SRAOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-420-3600
Mailing Address - Street 1:2600 E. SOUTHERN AVE.
Mailing Address - Street 2:I-1
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7738
Mailing Address - Country:US
Mailing Address - Phone:480-420-3600
Mailing Address - Fax:480-420-3644
Practice Address - Street 1:2600 E. SOUTHERN AVE.
Practice Address - Street 2:I-1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7738
Practice Address - Country:US
Practice Address - Phone:480-420-3600
Practice Address - Fax:480-420-3644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46748261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain