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General NPI Number Information
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NPI Number | 1932865409
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Entity Type | Organization
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Legal Business Name | ELEVATE SPORT AND SPINE, LLC
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Dates
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Enumeration Date | 11/09/2021
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Last Update Date | 06/05/2024
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Provider Practice Location Address
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Address Line | 101 PROFESSIONAL PARK PVT DR
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City | KINGSPORT
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State | TN
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Zip | 37663-2288
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Country | US
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Telephone | 423-239-9122
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Fax | 423-239-7991
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Provider Business Mailing Address
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Address Line | 4012 FORT HENRY DR
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City | KINGSPORT
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State | TN
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Zip | 37663-2028
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Country | US
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Telephone | 423-502-3776
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Fax | 423-239-7991
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Authorized Official
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Title or Position | OWNER/CEO/CHIROPRACTOR
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Name | PRESTON S DOUGLAS
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Credential | DC, CCSP, ATC
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Telephone | 423-239-9122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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