Provider Demographics
NPI:1235776691
Name:605 SPORT AND SPINE
Entity Type:Organization
Organization Name:605 SPORT AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:G
Authorized Official - Last Name:OZANNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC, ATC
Authorized Official - Phone:715-544-6364
Mailing Address - Street 1:2212 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-3661
Mailing Address - Country:US
Mailing Address - Phone:715-544-6364
Mailing Address - Fax:
Practice Address - Street 1:2212 DIVISION ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3661
Practice Address - Country:US
Practice Address - Phone:715-544-6364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-04
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center