Provider Demographics
NPI:1811036346
Name:FUNCTIONAL SPINE CENTER, PA
Entity Type:Organization
Organization Name:FUNCTIONAL SPINE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELKO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-777-7711
Mailing Address - Street 1:185 WEBSTER ST STE 15
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5500
Mailing Address - Country:US
Mailing Address - Phone:207-777-7711
Mailing Address - Fax:207-777-7712
Practice Address - Street 1:185 WEBSTER ST STE 15
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5500
Practice Address - Country:US
Practice Address - Phone:207-777-7711
Practice Address - Fax:207-777-7712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty