Provider Demographics
NPI:1346487170
Name:JEFFERSON PARK SPINE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:JEFFERSON PARK SPINE SPECIALISTS, LLC
Other - Org Name:MEDINA SPORTS AND FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-920-1681
Mailing Address - Street 1:748 GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-1042
Mailing Address - Country:US
Mailing Address - Phone:330-920-1681
Mailing Address - Fax:330-920-1669
Practice Address - Street 1:8803 BRECKSVILLE RD STE 13
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-1990
Practice Address - Country:US
Practice Address - Phone:330-920-1681
Practice Address - Fax:330-920-1669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON PARK SPINE SPECIALIST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-15
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2353528Medicaid
OH0189203Medicaid
OHU88289Medicare UPIN