Healthcare Provider Details

I. General information

NPI: 1639565716
Provider Name (Legal Business Name): SPORT & SPINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 A AVE
HIAWATHA IA
52233-1504
US

IV. Provider business mailing address

3109 LEONARD TER NE
CEDAR RAPIDS IA
52402-4148
US

V. Phone/Fax

Practice location:
  • Phone: 319-892-3363
  • Fax: 319-892-3034
Mailing address:
  • Phone: 319-491-4242
  • Fax: 319-892-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number007394
License Number StateIA

VIII. Authorized Official

Name: DR. NATHAN ROBERT WEBER
Title or Position: DOCTOR/OWNER
Credential: DC MS
Phone: 319-491-4242