Provider Demographics
NPI:1407675556
Name:ADVANCED SPINE AND SPORT CLINIC, PLLC
Entity type:Organization
Organization Name:ADVANCED SPINE AND SPORT CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-781-6035
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-0955
Mailing Address - Country:US
Mailing Address - Phone:435-781-6035
Mailing Address - Fax:435-781-6040
Practice Address - Street 1:1783 W 1000 S
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-4115
Practice Address - Country:US
Practice Address - Phone:435-781-6035
Practice Address - Fax:435-781-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty