Provider Demographics
NPI:1215600507
Name:EXPRESS SPORT AND SPINE S.C.
Entity Type:Organization
Organization Name:EXPRESS SPORT AND SPINE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DREES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-934-8542
Mailing Address - Street 1:425 W MAIN ST STE 101B
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-2971
Mailing Address - Country:US
Mailing Address - Phone:608-514-1842
Mailing Address - Fax:
Practice Address - Street 1:425 W MAIN ST STE 101B
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2971
Practice Address - Country:US
Practice Address - Phone:608-514-1842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-01
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty