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General NPI Number Information
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NPI Number | 1083297915
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Entity Type | Organization
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Legal Business Name | SPINAL SOLUTIONS HEALTH AND WELLNESS
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Dates
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Enumeration Date | 04/29/2021
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Last Update Date | 05/31/2021
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Provider Practice Location Address
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Address Line | 276 PASEO REYES DR
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City | ST AUGUSTINE
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State | FL
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Zip | 32095-8462
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Country | US
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Telephone | 570-778-0083
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Fax |
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Provider Business Mailing Address
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Address Line | 200 FRONT DOOR LN
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City | ST AUGUSTINE
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State | FL
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Zip | 32095-8543
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Country | US
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Telephone | 570-778-0083
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. DEREK SISAK
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Credential | DC
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Telephone | 570-778-0083
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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