Provider Demographics
NPI:1538642087
Name:REGIONAL SPORT AND SPINE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:REGIONAL SPORT AND SPINE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-465-1140
Mailing Address - Street 1:4004 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-1773
Mailing Address - Country:US
Mailing Address - Phone:219-465-1140
Mailing Address - Fax:219-465-0903
Practice Address - Street 1:4004 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-1773
Practice Address - Country:US
Practice Address - Phone:219-465-1140
Practice Address - Fax:219-465-0903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08002287AOtherSTATE LICENSE NUMBER
IN300009256Medicaid