Provider Demographics
NPI:1619787959
Name:SHORELINE SPORT & SPINE PC
Entity type:Organization
Organization Name:SHORELINE SPORT & SPINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SYTSEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-847-1280
Mailing Address - Street 1:18000 COVE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1383
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:616-847-1290
Practice Address - Street 1:2073 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1535
Practice Address - Country:US
Practice Address - Phone:231-744-0077
Practice Address - Fax:616-847-1290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-09
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty