Provider Demographics
NPI:1881355303
Name:CONRAD SPINE AND SPORT
Entity type:Organization
Organization Name:CONRAD SPINE AND SPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:469-552-5904
Mailing Address - Street 1:5000 WHITESTONE LN APT 1431
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3039
Mailing Address - Country:US
Mailing Address - Phone:417-350-5722
Mailing Address - Fax:
Practice Address - Street 1:8765 STOCKARD DR STE 901
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-8009
Practice Address - Country:US
Practice Address - Phone:469-552-5904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-06
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750054672OtherNPI 1 NUMBER