Provider Demographics
NPI:1013593748
Name:SPORTS AND SPINE HEALTHCARE LLC
Entity Type:Organization
Organization Name:SPORTS AND SPINE HEALTHCARE LLC
Other - Org Name:EVERGREEN HEALTHCARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRISHMA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:848-219-2657
Mailing Address - Street 1:1027 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5838
Mailing Address - Country:US
Mailing Address - Phone:856-691-6055
Mailing Address - Fax:
Practice Address - Street 1:1027 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5838
Practice Address - Country:US
Practice Address - Phone:856-691-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty