Provider Demographics
NPI:1194298182
Name:SPINE AND SPORT CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:SPINE AND SPORT CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:NYREN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-507-7564
Mailing Address - Street 1:8520 STEILACOOM BLVD SW STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-4773
Mailing Address - Country:US
Mailing Address - Phone:253-507-7564
Mailing Address - Fax:253-625-7241
Practice Address - Street 1:8520 STEILACOOM BLVD SW STE 101
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-4773
Practice Address - Country:US
Practice Address - Phone:253-507-7564
Practice Address - Fax:253-625-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-02
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty