MEDICARE: SPINE AND SPORT CHIROPRACTIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1194298182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND SPORT CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	8520 STEILACOOM BLVD SW STE 101
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-4773
Country	:	US
Telephone Number	:	253-507-7564
Fax Number	:	253-625-7241

Provider Business Practice Location Address
First Line	:	8520 STEILACOOM BLVD SW STE 101
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-4773
Country	:	US
Telephone Number	:	253-507-7564
Fax Number	:	253-625-7241

Authorized Official
Title or Position	:	OWNER/CHIROPRACTOR
Name	:	DR. DEREK NYREN
Credential	:	DC
Telephone Number	:	253-507-7564

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	07/18/2019

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