Provider Demographics
NPI:1609288802
Name:SPINE & SPORT REHABILITATION INSTITUTE
Entity Type:Organization
Organization Name:SPINE & SPORT REHABILITATION INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/TREATING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-861-9559
Mailing Address - Street 1:217 JAMESTOWN PARK
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-1500
Mailing Address - Country:US
Mailing Address - Phone:615-861-9559
Mailing Address - Fax:615-704-0039
Practice Address - Street 1:217 JAMESTOWN PARK
Practice Address - Street 2:SUITE 5
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-1500
Practice Address - Country:US
Practice Address - Phone:615-861-9559
Practice Address - Fax:615-704-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty