Provider Demographics
NPI:1336325257
Name:ADVANCED SPINE & REHABILITATION
Entity Type:Organization
Organization Name:ADVANCED SPINE & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-656-0234
Mailing Address - Street 1:619 S BLUFF ST
Mailing Address - Street 2:TOWER 1 STE 400
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3853
Mailing Address - Country:US
Mailing Address - Phone:435-656-0234
Mailing Address - Fax:435-656-2622
Practice Address - Street 1:619 S BLUFF ST
Practice Address - Street 2:TOWER 1 STE 400
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3853
Practice Address - Country:US
Practice Address - Phone:435-656-0234
Practice Address - Fax:435-656-2622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPENDINGMedicare PIN