Provider Demographics
NPI:1285818641
Name:CHIROPRACTIC SPORTS & WELLNESS PC
Entity Type:Organization
Organization Name:CHIROPRACTIC SPORTS & WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CASSISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-635-7727
Mailing Address - Street 1:1019 E LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4843
Mailing Address - Country:US
Mailing Address - Phone:307-635-7727
Mailing Address - Fax:307-638-0423
Practice Address - Street 1:1021 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4851
Practice Address - Country:US
Practice Address - Phone:307-635-7727
Practice Address - Fax:307-638-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty