Provider Demographics
NPI:1427383157
Name:ADVANCED SPINAL CARE, LLC
Entity Type:Organization
Organization Name:ADVANCED SPINAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:TENILE
Authorized Official - Last Name:PERGANDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-381-1208
Mailing Address - Street 1:310 CADY AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1419
Mailing Address - Country:US
Mailing Address - Phone:253-381-1208
Mailing Address - Fax:
Practice Address - Street 1:1052 OAK FOREST DR STE 210
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-3427
Practice Address - Country:US
Practice Address - Phone:608-783-0384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4536-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty