Provider Demographics
NPI:1669162475
Name:OPTIMAL SPINE AND SPORTS MEDICINE PLLC
Entity type:Organization
Organization Name:OPTIMAL SPINE AND SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:830-688-9651
Mailing Address - Street 1:319 SIKES ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-4528
Mailing Address - Country:US
Mailing Address - Phone:830-688-9651
Mailing Address - Fax:
Practice Address - Street 1:6212 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77009-2496
Practice Address - Country:US
Practice Address - Phone:830-688-9651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty