Basic Information
| Provider Information | |||||||||
| NPI: | 1932317666 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPINALAID, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TEAM CHIROPRACTIC, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 N STATE ROAD 267 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461238475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172724100 | ||||||||
| FaxNumber: | 3172724110 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 N STATE ROAD 267 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461238475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172724100 | ||||||||
| FaxNumber: | 3172724110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 12/11/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DETTMER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LOU | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3172724100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 08000607A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 111NR0200X | 08000607A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Radiology | 2085R0202X | 99018585A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207Q00000X | 01017401 | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.