Provider Demographics
NPI:1508324260
Name:SPINE AND SPORT HEALTH CENTER P.A.
Entity Type:Organization
Organization Name:SPINE AND SPORT HEALTH CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:STROMME
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-895-1600
Mailing Address - Street 1:4203 HIGHWAY 13 W
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1569
Mailing Address - Country:US
Mailing Address - Phone:952-895-1600
Mailing Address - Fax:952-895-1710
Practice Address - Street 1:4203 HIGHWAY 13 W
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1569
Practice Address - Country:US
Practice Address - Phone:952-895-1600
Practice Address - Fax:952-895-1710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE AND SPORT HEALTH P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1396272548Medicaid
MN1093107690Medicaid