Provider Demographics
NPI:1861816563
Name:LASER SPORT & SPINE, INC.
Entity Type:Organization
Organization Name:LASER SPORT & SPINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MILAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-254-5765
Mailing Address - Street 1:10350 KILBY CT
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-5825
Mailing Address - Country:US
Mailing Address - Phone:804-254-5765
Mailing Address - Fax:804-254-5763
Practice Address - Street 1:1303 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4851
Practice Address - Country:US
Practice Address - Phone:804-254-5765
Practice Address - Fax:804-254-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-15
Last Update Date:2014-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-555801111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1972714079OtherDOCTOR'S PRIOR INDIVIDUAL NPI #