Provider Demographics
NPI:1568935120
Name:VATRA SPINA AND SPORT LLC
Entity Type:Organization
Organization Name:VATRA SPINA AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:516-432-2100
Mailing Address - Street 1:4454 AUSTIN BVLD.
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558
Mailing Address - Country:US
Mailing Address - Phone:516-432-2100
Mailing Address - Fax:
Practice Address - Street 1:4454 AUSTIN BVLD.
Practice Address - Street 2:
Practice Address - City:ISLAND PARK
Practice Address - State:NY
Practice Address - Zip Code:11558-1155
Practice Address - Country:US
Practice Address - Phone:516-432-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty