Provider Demographics
NPI:1487198677
Name:SPINE DYNAMICS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SPINE DYNAMICS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANOS-TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-229-4500
Mailing Address - Street 1:660 CASCADE WEST PKWY SE STE 25
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2142
Mailing Address - Country:US
Mailing Address - Phone:616-229-4500
Mailing Address - Fax:616-228-9828
Practice Address - Street 1:660 CASCADE WEST PKWY SE STE 25
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2142
Practice Address - Country:US
Practice Address - Phone:616-229-4500
Practice Address - Fax:616-228-9828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006157225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501006157OtherSTATE LICENSE
MI1700832805Medicaid
MI5501006157OtherSTATE LICENSE