Provider Demographics
NPI:1093058067
Name:SP SPINE CENTER P A
Entity Type:Organization
Organization Name:SP SPINE CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:P
Authorized Official - Last Name:WANGERIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-207-4879
Mailing Address - Street 1:441 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-2085
Mailing Address - Country:US
Mailing Address - Phone:651-207-4879
Mailing Address - Fax:651-207-4028
Practice Address - Street 1:441 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2085
Practice Address - Country:US
Practice Address - Phone:651-207-4879
Practice Address - Fax:651-207-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4841111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty