Provider Demographics
NPI:1578860664
Name:DYNAMIC SPINE AND JOINT CENTER LLC
Entity Type:Organization
Organization Name:DYNAMIC SPINE AND JOINT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-219-5344
Mailing Address - Street 1:3000 IOWA ST
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4926
Mailing Address - Country:US
Mailing Address - Phone:618-219-5344
Mailing Address - Fax:
Practice Address - Street 1:4917 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-2644
Practice Address - Country:US
Practice Address - Phone:618-219-5344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty