Provider Demographics
NPI:1689440950
Name:REACTIV SPORT AND SPINE, LLC
Entity Type:Organization
Organization Name:REACTIV SPORT AND SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-850-1446
Mailing Address - Street 1:710 E PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-8854
Mailing Address - Country:US
Mailing Address - Phone:972-850-1446
Mailing Address - Fax:
Practice Address - Street 1:710 E PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-8854
Practice Address - Country:US
Practice Address - Phone:972-850-1446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty