Basic Information
| Provider Information | |||||||||
| NPI: | 1760811822 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUECHIP SPINE & SPORTS SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8336 E 21ST ST N | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672062948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167338338 | ||||||||
| FaxNumber: | 3167338343 | ||||||||
| Practice Location | |||||||||
| Address1: | 8336 E 21ST ST N | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672062948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167338338 | ||||||||
| FaxNumber: | 3167338343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2013 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUMMEL | ||||||||
| AuthorizedOfficialFirstName: | CASEY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3167338338 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NS0005X | 01-05122 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Sports Physician |
No ID Information.