Provider Demographics
NPI:1699726208
Name:NORTH COUNTY SPINE AND SPORTS
Entity type:Organization
Organization Name:NORTH COUNTY SPINE AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PT
Authorized Official - Phone:716-366-2229
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:4867 WEST LAKE ST SUITE 6
Mailing Address - City:DUNKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:14048-0070
Mailing Address - Country:US
Mailing Address - Phone:716-366-2229
Mailing Address - Fax:716-366-7874
Practice Address - Street 1:4867 W LAKE RD STE 6
Practice Address - Street 2:SUITE 6
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-9613
Practice Address - Country:US
Practice Address - Phone:716-366-2229
Practice Address - Fax:716-366-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009274261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA0894Medicare PIN