Provider Demographics
NPI:1962530659
Name:SPINE & SPORT INSTITUTE, INC.
Entity type:Organization
Organization Name:SPINE & SPORT INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RODD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CERT MDT
Authorized Official - Phone:772-567-8040
Mailing Address - Street 1:1345 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4848
Mailing Address - Country:US
Mailing Address - Phone:772-567-8040
Mailing Address - Fax:772-567-8420
Practice Address - Street 1:1345 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4848
Practice Address - Country:US
Practice Address - Phone:772-567-8040
Practice Address - Fax:772-567-8420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT#007940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY5581OtherBCBS PROVIDER #
FLK8662Medicare ID - Type UnspecifiedMC PROVIDER #