Provider Demographics
NPI:1942647466
Name:CHIROPRACTIC SPORT & SPINE CENTER INC
Entity Type:Organization
Organization Name:CHIROPRACTIC SPORT & SPINE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUNNAR
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-322-3177
Mailing Address - Street 1:1000 EAGLE RIDGE DRIVE
Mailing Address - Street 2:STE A
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-4208
Mailing Address - Country:US
Mailing Address - Phone:219-322-3177
Mailing Address - Fax:219-322-3209
Practice Address - Street 1:1000 EAGLE RIDGE DRIVE
Practice Address - Street 2:STE A
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-4208
Practice Address - Country:US
Practice Address - Phone:219-322-3177
Practice Address - Fax:219-322-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001355A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU19153Medicare UPIN