Provider Demographics
NPI:1942353743
Name:SPINE & SPORT CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:SPINE & SPORT CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:205-393-4308
Mailing Address - Street 1:1800 MCFARLAND BLVD E STE 340
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-5882
Mailing Address - Country:US
Mailing Address - Phone:205-393-4308
Mailing Address - Fax:
Practice Address - Street 1:1800 MCFARLAND BLVD E STE 340
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5882
Practice Address - Country:US
Practice Address - Phone:205-393-4308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51527164OtherBCBS
AL1104860766OtherINDIVIDUAL NPI
AL51527164OtherBCBS
AL051527164Medicare ID - Type Unspecified