=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578334017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINALLY BETTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2024
-----------------------------------------------------
Last Update Date | 01/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4949 AUTUMN OAKS DR STE A
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-8557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-774-6252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 269 HARBOR MILL DR
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62294-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-774-6252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. CAMERON GORDINEER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 757-774-6252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------