Provider Demographics
NPI:1467694729
Name:SOUTHEAST SPINE & WELLNESS CENTER LLC
Entity type:Organization
Organization Name:SOUTHEAST SPINE & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GENTHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-399-4700
Mailing Address - Street 1:355 CRAWFORD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2816
Mailing Address - Country:US
Mailing Address - Phone:757-399-4700
Mailing Address - Fax:757-399-0011
Practice Address - Street 1:355 CRAWFORD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2816
Practice Address - Country:US
Practice Address - Phone:757-399-4700
Practice Address - Fax:757-399-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty