Provider Demographics
NPI:1053690677
Name:SPINE AND SPORTS INJURY CENTER, LLC
Entity type:Organization
Organization Name:SPINE AND SPORTS INJURY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:907-376-2225
Mailing Address - Street 1:1001 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7114
Mailing Address - Country:US
Mailing Address - Phone:907-376-2225
Mailing Address - Fax:907-376-9225
Practice Address - Street 1:1001 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7114
Practice Address - Country:US
Practice Address - Phone:907-376-2225
Practice Address - Fax:907-376-9225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK435111NS0005X
207Q00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty