Provider Demographics
NPI:1114352853
Name:CENTRAL SPORT AND SPINE LLC
Entity Type:Organization
Organization Name:CENTRAL SPORT AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-317-2944
Mailing Address - Street 1:160 SW SCALEHOUSE LOOP
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1284
Mailing Address - Country:US
Mailing Address - Phone:541-617-9969
Mailing Address - Fax:541-617-9890
Practice Address - Street 1:160 SW SCALEHOUSE LOOP
Practice Address - Street 2:SUITE 140
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1284
Practice Address - Country:US
Practice Address - Phone:541-617-9969
Practice Address - Fax:541-617-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5125111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty