Provider Demographics
NPI:1659745024
Name:MIDWEST SPORT AND SPINE INC
Entity Type:Organization
Organization Name:MIDWEST SPORT AND SPINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHOUKHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMVICHIT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-397-1179
Mailing Address - Street 1:730 N FRANKLIN ST
Mailing Address - Street 2:SUITE 602
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3563
Mailing Address - Country:US
Mailing Address - Phone:312-397-1179
Mailing Address - Fax:773-337-9106
Practice Address - Street 1:730 N FRANKLIN ST
Practice Address - Street 2:SUITE 602
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3563
Practice Address - Country:US
Practice Address - Phone:312-397-1179
Practice Address - Fax:773-337-9106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-21
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty