Healthcare Provider Details

I. General information

NPI: 1447872346
Provider Name (Legal Business Name): ELITE SPINE CARE OF KANSAS CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 W 87TH TER
PRAIRIE VILLAGE KS
66207-2271
US

IV. Provider business mailing address

180 N MICHIGAN AVE STE 500
CHICAGO IL
60601-7426
US

V. Phone/Fax

Practice location:
  • Phone: 913-649-7300
  • Fax:
Mailing address:
  • Phone: 312-796-9483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: GLENN AMUNDSON
Title or Position: OWNER
Credential:
Phone: 913-649-7300