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General NPI Number Information
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NPI Number | 1518397801
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Entity Type | Organization
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Legal Business Name | INDIANA SPINE AND SPORTS INC.
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Dates
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Enumeration Date | 11/22/2013
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Last Update Date | 11/22/2013
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Provider Practice Location Address
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Address Line | 418 S WALNUT ST SUITE C
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City | BLOOMINGTON
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State | IN
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Zip | 47401
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Country | US
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Telephone | 812-822-2545
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Fax | 812-822-2591
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Provider Business Mailing Address
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Address Line | 418 S WALNUT ST SUITE C
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City | BLOOMINGTON
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State | IN
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Zip | 47401
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Country | US
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Telephone | 812-822-2545
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Fax | 812-822-2591
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | AMANDA JO SMITH
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Credential | D.C
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Telephone | 812-345-1930
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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 | 08002499A
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License Number State | IN
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