Provider Demographics
NPI:1194315846
Name:SPINE STOP LAFAYETTE, PLLC
Entity type:Organization
Organization Name:SPINE STOP LAFAYETTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-208-8163
Mailing Address - Street 1:352 OLD GALLATIN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-8666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 HIGHWAY 52 BYP W
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-2636
Practice Address - Country:US
Practice Address - Phone:270-237-3304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty