Provider Demographics
NPI:1528156072
Name:SPINE & SPORT CLINIC
Entity type:Organization
Organization Name:SPINE & SPORT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DC
Authorized Official - Prefix:
Authorized Official - First Name:CORINA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-340-1958
Mailing Address - Street 1:72405 PARK VIEW DRIVE, STE. A
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3317
Mailing Address - Country:US
Mailing Address - Phone:760-340-1958
Mailing Address - Fax:760-340-2280
Practice Address - Street 1:72405 PARK VIEW DRIVE, STE. A
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3317
Practice Address - Country:US
Practice Address - Phone:760-340-1958
Practice Address - Fax:760-340-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC025209111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID NUMBER