Provider Demographics
NPI:1104236264
Name:SPORTS PERFORMANCE AND SPINE, LLC
Entity type:Organization
Organization Name:SPORTS PERFORMANCE AND SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:724-519-8261
Mailing Address - Street 1:4491 SCHOOL RD S
Mailing Address - Street 2:
Mailing Address - City:MURRYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15632-1809
Mailing Address - Country:US
Mailing Address - Phone:724-519-8261
Mailing Address - Fax:
Practice Address - Street 1:4491 SCHOOL RD S
Practice Address - Street 2:
Practice Address - City:MURRYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15632-1809
Practice Address - Country:US
Practice Address - Phone:724-519-8261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009953261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center