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General NPI Number Information
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NPI Number | 1871894816
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Entity Type | Organization
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Legal Business Name | THE SUBLIME SPINE, LLC
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Dates
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Enumeration Date | 11/08/2010
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Last Update Date | 11/08/2010
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Provider Practice Location Address
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Address Line | 1175 FOLLY RD SUITE E
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City | CHARLESTON
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State | SC
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Zip | 29412-4130
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Country | US
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Telephone | 843-225-1236
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Fax | 843-225-1237
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Provider Business Mailing Address
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Address Line | 1175 FOLLY RD SUITE E
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City | CHARLESTON
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State | SC
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Zip | 29412-4130
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Country | US
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Telephone | 843-225-1236
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Fax | 843-225-1237
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Authorized Official
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Title or Position | OWNER
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Name | DR. LEE DAVID RUSSO
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Credential | DC
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Telephone | 843-225-1236
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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 | 3605
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License Number State | SC
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