Provider Demographics
NPI:1174719199
Name:SPORTS & SPINAL INJURY CLINIC, LLC
Entity type:Organization
Organization Name:SPORTS & SPINAL INJURY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUETTL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:907-522-3511
Mailing Address - Street 1:6634 LAKE OTIS PKWY
Mailing Address - Street 2:A
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2176
Mailing Address - Country:US
Mailing Address - Phone:907-522-3511
Mailing Address - Fax:907-522-8551
Practice Address - Street 1:6634 LAKE OTIS PKWY
Practice Address - Street 2:A
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-2176
Practice Address - Country:US
Practice Address - Phone:907-522-3511
Practice Address - Fax:907-522-8551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH0328Medicaid
AKK151178Medicare PIN
AKK151179Medicare PIN
AKCH0328Medicaid