Provider Demographics
NPI:1518381938
Name:SPORTS PERFORMANCE CONCEPTS, LLC
Entity Type:Organization
Organization Name:SPORTS PERFORMANCE CONCEPTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:CORTJENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP, QME, IIE
Authorized Official - Phone:470-239-0770
Mailing Address - Street 1:3985 LAKEFIELD CT STE 206
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1209
Mailing Address - Country:US
Mailing Address - Phone:470-239-0770
Mailing Address - Fax:
Practice Address - Street 1:3985 LAKEFIELD CT STE 206
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1209
Practice Address - Country:US
Practice Address - Phone:470-239-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009018111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1467144220OtherTYPE 1 NPI FOR IR
GA1063760635OtherTYPE I NPI
GA1518380938OtherTYPE 2 NPI