Provider Demographics
NPI:1730363607
Name:SPINE AND SPORTS INSITUTE, LLC
Entity type:Organization
Organization Name:SPINE AND SPORTS INSITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LACHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-315-0466
Mailing Address - Street 1:9325 UPLAND LN N
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4200
Mailing Address - Country:US
Mailing Address - Phone:763-315-0466
Mailing Address - Fax:763-315-0884
Practice Address - Street 1:9325 UPLAND LN N
Practice Address - Street 2:SUITE 230
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4200
Practice Address - Country:US
Practice Address - Phone:763-315-0466
Practice Address - Fax:763-315-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherTID