Provider Demographics
NPI:1841411162
Name:SPINE CENTER III, INC
Entity Type:Organization
Organization Name:SPINE CENTER III, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOSTUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-231-4003
Mailing Address - Street 1:1929 BLANKENBAKER PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2403
Mailing Address - Country:US
Mailing Address - Phone:502-266-5662
Mailing Address - Fax:502-266-5565
Practice Address - Street 1:1929 BLANKENBAKER PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2403
Practice Address - Country:US
Practice Address - Phone:502-266-5662
Practice Address - Fax:502-266-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4532111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty