Healthcare Provider Details

I. General information

NPI: 1942563259
Provider Name (Legal Business Name): SPINALCARE PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N AVON AVE
AVON IN
46123-8475
US

IV. Provider business mailing address

114 N AVON AVE
AVON IN
46123-8475
US

V. Phone/Fax

Practice location:
  • Phone: 317-272-4100
  • Fax: 317-272-4110
Mailing address:
  • Phone: 317-272-4100
  • Fax: 317-272-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN A DETTMER
Title or Position: OWNER
Credential: D.C.
Phone: 317-272-4100