Healthcare Provider Details

I. General information

NPI: 1407420664
Provider Name (Legal Business Name): FUNCTION FIRST SPINE AND SPORT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SUMNER AVE
HUMBOLDT IA
50548-1761
US

IV. Provider business mailing address

1371 NELSON AVE
FORT DODGE IA
50501-8534
US

V. Phone/Fax

Practice location:
  • Phone: 515-570-7695
  • Fax:
Mailing address:
  • Phone: 525-570-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA S VANSICKLER
Title or Position: OWNER
Credential: DC, CCSP
Phone: 515-570-7695