Provider Demographics
NPI:1164661955
Name:SPORT, SPINE & REHAB, LLC
Entity type:Organization
Organization Name:SPORT, SPINE & REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:WENTWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC, ATC
Authorized Official - Phone:207-439-9045
Mailing Address - Street 1:28 LEVESQUE DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ELIOT
Mailing Address - State:ME
Mailing Address - Zip Code:03903-2078
Mailing Address - Country:US
Mailing Address - Phone:207-439-9045
Mailing Address - Fax:207-703-0289
Practice Address - Street 1:28 LEVESQUE DR
Practice Address - Street 2:SUITE 9
Practice Address - City:ELIOT
Practice Address - State:ME
Practice Address - Zip Code:03903
Practice Address - Country:US
Practice Address - Phone:207-439-9045
Practice Address - Fax:207-703-0289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty