Healthcare Provider Details

I. General information

NPI: 1669240073
Provider Name (Legal Business Name): LEGACY SPINE AND SPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MILL ST
REEDSVILLE WI
54230-1700
US

IV. Provider business mailing address

106 MILL ST
REEDSVILLE WI
54230-1700
US

V. Phone/Fax

Practice location:
  • Phone: 920-901-3382
  • Fax:
Mailing address:
  • Phone: 920-588-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. COLBY KASTEN
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 920-588-7171