Provider Demographics
NPI:1487374930
Name:SPINE & SPORT PHYSICAL THERAPIST CARE LLC
Entity type:Organization
Organization Name:SPINE & SPORT PHYSICAL THERAPIST CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:865-332-7422
Mailing Address - Street 1:402 S WILSON DAM RD
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3662
Mailing Address - Country:US
Mailing Address - Phone:865-332-7422
Mailing Address - Fax:
Practice Address - Street 1:402 S WILSON DAM RD
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3662
Practice Address - Country:US
Practice Address - Phone:256-715-5868
Practice Address - Fax:256-253-5633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-02
Last Update Date:2023-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty