Provider Demographics
NPI:1942541222
Name:SPORT SPINE & WELLNESS, PLLC
Entity Type:Organization
Organization Name:SPORT SPINE & WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-703-9676
Mailing Address - Street 1:1664 S DIXIE DR
Mailing Address - Street 2:STE. F-103
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7327
Mailing Address - Country:US
Mailing Address - Phone:435-703-9676
Mailing Address - Fax:
Practice Address - Street 1:1664 S DIXIE DR
Practice Address - Street 2:STE. F-103
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7327
Practice Address - Country:US
Practice Address - Phone:435-703-9676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8536048-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty