Provider Demographics
NPI:1164821963
Name:SPORT AND SPINE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:SPORT AND SPINE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:REES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:741-741-5300
Mailing Address - Street 1:19 BAY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-3501
Mailing Address - Country:US
Mailing Address - Phone:781-741-5300
Mailing Address - Fax:
Practice Address - Street 1:185 LINCOLN ST
Practice Address - Street 2:#110
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-1743
Practice Address - Country:US
Practice Address - Phone:781-741-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3059111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1679546840OtherNPI
MAV08534Medicare UPIN
MAY45833Medicare PIN