Provider Demographics
NPI:1639318173
Name:PETERSBURG SPINE & SPORT INC
Entity Type:Organization
Organization Name:PETERSBURG SPINE & SPORT INC
Other - Org Name:PETERSBURG SPINE & SPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GENSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-632-7599
Mailing Address - Street 1:115 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62675-1558
Mailing Address - Country:US
Mailing Address - Phone:217-632-7599
Mailing Address - Fax:
Practice Address - Street 1:115 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675-1558
Practice Address - Country:US
Practice Address - Phone:217-632-7599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty