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General NPI Number Information
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NPI Number | 1912390808
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Entity Type | Organization
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Legal Business Name | PRECISION SPORT AND SPINE, LLC
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Dates
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Enumeration Date | 03/17/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 4460 N ILLINOIS ST SUITE 5
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City | SWANSEA
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State | IL
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Zip | 62226-1899
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Country | US
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Telephone | 618-234-4277
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Fax | 618-257-3291
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Provider Business Mailing Address
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Address Line | 4460 N ILLINOIS ST SUITE 5
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City | SWANSEA
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State | IL
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Zip | 62226-1899
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Country | US
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Telephone | 618-234-4277
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Fax | 618-257-3291
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Authorized Official
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Title or Position | OWNER
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Name | TYLER GREYSON WHITE
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Credential | D.C.
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Telephone | 618-234-4277
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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 | 038.012766
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License Number State | IL
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