Healthcare Provider Details

I. General information

NPI: 1083297915
Provider Name (Legal Business Name): SPINAL SOLUTIONS HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 05/31/2021
Certification Date: 05/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 PASEO REYES DR
ST AUGUSTINE FL
32095-8462
US

IV. Provider business mailing address

200 FRONT DOOR LN
ST AUGUSTINE FL
32095-8543
US

V. Phone/Fax

Practice location:
  • Phone: 570-778-0083
  • Fax:
Mailing address:
  • Phone: 570-778-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. DEREK SISAK
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 570-778-0083