Provider Demographics
NPI:1760479760
Name:SOUTHWEST SPORTS & SPINE, LLP
Entity type:Organization
Organization Name:SOUTHWEST SPORTS & SPINE, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:RETTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-529-3691
Mailing Address - Street 1:11661 PRESTON RD
Mailing Address - Street 2:SUITE 173
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2745
Mailing Address - Country:US
Mailing Address - Phone:214-265-7200
Mailing Address - Fax:214-265-7521
Practice Address - Street 1:11661 PRESTON RD
Practice Address - Street 2:SUITE 173
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2745
Practice Address - Country:US
Practice Address - Phone:214-265-7200
Practice Address - Fax:214-265-7521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX635850000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0033ELOtherBCBS
TX00990EMedicare ID - Type UnspecifiedMEDICARE FACILITY NUMBER