Provider Demographics
NPI:1073828430
Name:SPINE PERFORMANCE AND REHABILITATION CENTER
Entity Type:Organization
Organization Name:SPINE PERFORMANCE AND REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:425-894-5682
Mailing Address - Street 1:22433 NE MARKETPLACE DR APT L3082
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98053-1924
Mailing Address - Country:US
Mailing Address - Phone:425-894-5682
Mailing Address - Fax:
Practice Address - Street 1:22433 NE MARKETPLACE DR APT L3082
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98053-1924
Practice Address - Country:US
Practice Address - Phone:425-894-5682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty