Provider Demographics
NPI:1215139621
Name:SPINAL CARE CENTER, INC
Entity type:Organization
Organization Name:SPINAL CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:913-744-2973
Mailing Address - Street 1:15283 W 147TH DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-5002
Mailing Address - Country:US
Mailing Address - Phone:913-397-8882
Mailing Address - Fax:
Practice Address - Street 1:11960 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-2216
Practice Address - Country:US
Practice Address - Phone:913-744-2973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS02-4944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST710000Medicare ID - Type Unspecified