Healthcare Provider Details

I. General information

NPI: 1932865409
Provider Name (Legal Business Name): ELEVATE SPORT AND SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PROFESSIONAL PARK PVT DR
KINGSPORT TN
37663-2288
US

IV. Provider business mailing address

4012 FORT HENRY DR
KINGSPORT TN
37663-2028
US

V. Phone/Fax

Practice location:
  • Phone: 423-239-9122
  • Fax: 423-239-7991
Mailing address:
  • Phone: 423-502-3776
  • Fax: 423-239-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: PRESTON S DOUGLAS
Title or Position: OWNER/CEO/CHIROPRACTOR
Credential: DC, CCSP, ATC
Phone: 423-239-9122