Provider Demographics
NPI:1538477690
Name:SPINE CLINIC, LLC
Entity Type:Organization
Organization Name:SPINE CLINIC, LLC
Other - Org Name:COSENS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:COSENS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:620-223-2990
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-0589
Mailing Address - Country:US
Mailing Address - Phone:620-223-2990
Mailing Address - Fax:620-223-2991
Practice Address - Street 1:15 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-1410
Practice Address - Country:US
Practice Address - Phone:620-223-2990
Practice Address - Fax:620-223-2991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010013287111N00000X
KS01-05329111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty