Healthcare Provider Details

I. General information

NPI: 1083454540
Provider Name (Legal Business Name): NEUROSPORT CONCUSSION AND SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 SE TECH CENTER PL STE 350
VANCOUVER WA
98683-9575
US

IV. Provider business mailing address

1499 SE TECH CENTER PL STE 350
VANCOUVER WA
98683-9575
US

V. Phone/Fax

Practice location:
  • Phone: 360-326-2121
  • Fax:
Mailing address:
  • Phone: 360-326-2121
  • 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: ALICE L GRENIER
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-326-2121