Provider Demographics
NPI:1851858872
Name:TC CORE SPINE AND SPORT
Entity Type:Organization
Organization Name:TC CORE SPINE AND SPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:NOBLES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-922-9066
Mailing Address - Street 1:5250 W 74TH ST STE 8
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2229
Mailing Address - Country:US
Mailing Address - Phone:952-922-9066
Mailing Address - Fax:952-922-9663
Practice Address - Street 1:5250 W 74TH ST STE 8
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2229
Practice Address - Country:US
Practice Address - Phone:952-922-9066
Practice Address - Fax:952-922-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1427392570Medicaid