Provider Demographics
NPI:1902446792
Name:SPIRIT MOBILE THERAPY LLC
Entity type:Organization
Organization Name:SPIRIT MOBILE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-326-0528
Mailing Address - Street 1:7575 W WASHINGTON AVE STE 127-140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4333
Mailing Address - Country:US
Mailing Address - Phone:702-326-0528
Mailing Address - Fax:702-796-6310
Practice Address - Street 1:8695 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2839
Practice Address - Country:US
Practice Address - Phone:702-326-0528
Practice Address - Fax:702-796-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty