Provider Demographics
NPI:1376097279
Name:SPORT & SPINE LLC
Entity Type:Organization
Organization Name:SPORT & SPINE LLC
Other - Org Name:SPOKANE SPORT & SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:509-720-1117
Mailing Address - Street 1:5428 S REGAL ST
Mailing Address - Street 2:PO BOX 31032
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-8153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3209 E 57TH AVE
Practice Address - Street 2:STE F
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7040
Practice Address - Country:US
Practice Address - Phone:509-720-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60130771261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center