Provider Demographics
NPI:1053324277
Name:INDIANA SPINE CENTER, LLC
Entity Type:Organization
Organization Name:INDIANA SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-463-9510
Mailing Address - Street 1:1179 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3733
Mailing Address - Country:US
Mailing Address - Phone:724-463-9510
Mailing Address - Fax:724-463-9511
Practice Address - Street 1:1179 S 6TH ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3733
Practice Address - Country:US
Practice Address - Phone:724-463-9510
Practice Address - Fax:724-463-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA093829UJMMedicare ID - Type Unspecified
PAU94636Medicare UPIN