Provider Demographics
NPI:1083297915
Name:SPINAL SOLUTIONS HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:SPINAL SOLUTIONS HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:SISAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-778-0083
Mailing Address - Street 1:200 FRONT DOOR LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8543
Mailing Address - Country:US
Mailing Address - Phone:570-778-0083
Mailing Address - Fax:
Practice Address - Street 1:276 PASEO REYES DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8462
Practice Address - Country:US
Practice Address - Phone:570-778-0083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty