Provider Demographics
NPI:1043305824
Name:SPORT, SPINE & ORTHOPEDIC
Entity type:Organization
Organization Name:SPORT, SPINE & ORTHOPEDIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:ST VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:805-541-4717
Mailing Address - Street 1:862 MEINECKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-3702
Mailing Address - Country:US
Mailing Address - Phone:805-541-4717
Mailing Address - Fax:805-541-4235
Practice Address - Street 1:862 MEINECKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-3702
Practice Address - Country:US
Practice Address - Phone:805-541-4714
Practice Address - Fax:805-541-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CAPT5452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14874Medicare ID - Type UnspecifiedPROVIDER #