Provider Demographics
NPI:1407420664
Name:FUNCTION FIRST SPINE AND SPORT, PLLC
Entity Type:Organization
Organization Name:FUNCTION FIRST SPINE AND SPORT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VANSICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:515-570-7695
Mailing Address - Street 1:1371 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-8534
Mailing Address - Country:US
Mailing Address - Phone:525-570-7695
Mailing Address - Fax:
Practice Address - Street 1:604 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-1761
Practice Address - Country:US
Practice Address - Phone:515-570-7695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1235495615Medicaid