Provider Demographics
NPI:1083454540
Name:NEUROSPORT CONCUSSION AND SPINE
Entity type:Organization
Organization Name:NEUROSPORT CONCUSSION AND SPINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRENIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-326-2121
Mailing Address - Street 1:1499 SE TECH CENTER PL STE 350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9575
Mailing Address - Country:US
Mailing Address - Phone:360-326-2121
Mailing Address - Fax:
Practice Address - Street 1:1499 SE TECH CENTER PL STE 350
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9575
Practice Address - Country:US
Practice Address - Phone:360-326-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-30
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty