=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356738645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRCREST SPINE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 11/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4916 CENTER ST SUITE G
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-912-9653
-----------------------------------------------------
Fax | 253-912-9660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4916 CENTER ST SUITE G
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-2348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-912-9653
-----------------------------------------------------
Fax | 253-912-9660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CODY F SANDZIMIER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 253-912-9653
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------