Provider Demographics
NPI:1801263256
Name:SPINE AND SPORT CENTER
Entity type:Organization
Organization Name:SPINE AND SPORT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SITKO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-525-2035
Mailing Address - Street 1:205 N GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2550
Mailing Address - Country:US
Mailing Address - Phone:217-525-2035
Mailing Address - Fax:
Practice Address - Street 1:205 N GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2550
Practice Address - Country:US
Practice Address - Phone:217-525-2035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty