Provider Demographics
NPI:1649787631
Name:DYNAMIC SPINE AND PERFORMANCE CENTER, LLC
Entity type:Organization
Organization Name:DYNAMIC SPINE AND PERFORMANCE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:281-770-3613
Mailing Address - Street 1:11511 KATY FWY
Mailing Address - Street 2:SUITE 418
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-1903
Mailing Address - Country:US
Mailing Address - Phone:713-955-7972
Mailing Address - Fax:713-588-8445
Practice Address - Street 1:11511 KATY FWY
Practice Address - Street 2:SUITE 418
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-1903
Practice Address - Country:US
Practice Address - Phone:713-955-7972
Practice Address - Fax:713-588-8445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty