Healthcare Provider Details

I. General information

NPI: 1528156072
Provider Name (Legal Business Name): SPINE & SPORT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72405 PARK VIEW DRIVE, STE. A
PALM DESERT CA
92260-3317
US

IV. Provider business mailing address

72405 PARK VIEW DRIVE, STE. A
PALM DESERT CA
92260-3317
US

V. Phone/Fax

Practice location:
  • Phone: 760-340-1958
  • Fax: 760-340-2280
Mailing address:
  • Phone: 760-340-1958
  • Fax: 760-340-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC025209
License Number StateCA

VIII. Authorized Official

Name: CORINA LYNN MORRISON
Title or Position: OWNER/DC
Credential: D.C.
Phone: 760-340-1958