Provider Demographics
NPI:1356655740
Name:SPORT & SPINAL REHAB
Entity Type:Organization
Organization Name:SPORT & SPINAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSEN
Authorized Official - Middle Name:TORREY
Authorized Official - Last Name:SUDNYKOVYCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-629-3501
Mailing Address - Street 1:275 TONEY PENNA DR STE 12
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5752
Mailing Address - Country:US
Mailing Address - Phone:561-746-4242
Mailing Address - Fax:561-746-7405
Practice Address - Street 1:275 TONEY PENNA DR STE 12
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5752
Practice Address - Country:US
Practice Address - Phone:561-746-4242
Practice Address - Fax:561-746-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty