Provider Demographics
NPI:1447275946
Name:SPINE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SPINE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-870-4401
Mailing Address - Street 1:PO BOX 632650
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2650
Mailing Address - Country:US
Mailing Address - Phone:702-268-7213
Mailing Address - Fax:702-818-5001
Practice Address - Street 1:3303 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4438
Practice Address - Country:US
Practice Address - Phone:801-373-7438
Practice Address - Fax:801-373-7486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty