Provider Demographics
NPI:1063799286
Name:LA SPORTS & SPINE, INC.
Entity type:Organization
Organization Name:LA SPORTS & SPINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-470-2909
Mailing Address - Street 1:10474 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6929
Mailing Address - Country:US
Mailing Address - Phone:310-470-2909
Mailing Address - Fax:310-470-3286
Practice Address - Street 1:10474 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6929
Practice Address - Country:US
Practice Address - Phone:310-470-2909
Practice Address - Fax:310-470-3286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18136111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty