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General NPI Number Information
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NPI Number | 1649516451
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Entity Type | Organization
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Legal Business Name | CONCORDIA SPINE & SPORT, LLC
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Dates
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Enumeration Date | 12/26/2012
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Last Update Date | 02/23/2023
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Provider Practice Location Address
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Address Line | 208 W 6TH ST
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City | CONCORDIA
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State | KS
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Zip | 66901-2817
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Country | US
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Telephone | 785-262-4344
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Fax |
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Provider Business Mailing Address
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Address Line | 208 W 6TH ST
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City | CONCORDIA
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State | KS
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Zip | 66901-2817
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | JEREMY WILL
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Credential | DC
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Telephone | 785-262-4344
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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 | 01-05450
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License Number State | KS
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