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1669240073 NPI number — LEGACY SPINE AND SPORT LLC

NPI Number: 1669240073
Health Care Provider/Practitioner: LEGACY SPINE AND SPORT LLC

Information about “1669240073” NPI (LEGACY SPINE AND SPORT LLC) exists in 1669240073 in HTML format HTML  |  1669240073 in plain Text format TXT  |  1669240073 in PDF (Portable Document Format) PDF  |  1669240073 in an XML format XML  formats.

NPI Number : 1669240073 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1669240073",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "LEGACY SPINE AND SPORT LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "106 MILL ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "REEDSVILLE",
    "MailingAddressStateName": "WI",
    "MailingAddressPostalCode": "54230-1700",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "920-588-7171",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "106 MILL ST",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "REEDSVILLE",
    "PracticeLocationAddressStateName": "WI",
    "PracticeLocationAddressPostalCode": "54230-1700",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "920-901-3382",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "12/14/2023",
    "LastUpdateDate": "04/19/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "KASTEN",
    "AuthorizedOfficialFirstName": "COLBY",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "CHIROPRACTOR",
    "AuthorizedOfficialNamePrefix": "DR.",
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DC",
    "AuthorizedOfficialTelephoneNumber": "920-588-7171",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "111N00000X",
        "TaxonomyName": "Chiropractor",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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