Provider Demographics
NPI:1639565716
Name:SPORT & SPINE PLLC
Entity Type:Organization
Organization Name:SPORT & SPINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DC MS
Authorized Official - Phone:319-491-4242
Mailing Address - Street 1:3109 LEONARD TER NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4148
Mailing Address - Country:US
Mailing Address - Phone:319-491-4242
Mailing Address - Fax:319-892-3034
Practice Address - Street 1:102 A AVE
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-1504
Practice Address - Country:US
Practice Address - Phone:319-892-3363
Practice Address - Fax:319-892-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2127Medicare Oscar/Certification
IAIB2127Medicare UPIN
IAIB2127Medicare PIN