Provider Demographics
NPI:1427309434
Name:SOUTHWEST SPORTS & SPINAL REHAB INC
Entity type:Organization
Organization Name:SOUTHWEST SPORTS & SPINAL REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:POTEKHINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-532-0000
Mailing Address - Street 1:16532 OAK PARK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2268
Mailing Address - Country:US
Mailing Address - Phone:708-532-0000
Mailing Address - Fax:
Practice Address - Street 1:16532 OAK PARK AVE STE 100
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2268
Practice Address - Country:US
Practice Address - Phone:708-532-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty