Provider Demographics
NPI:1871865550
Name:NORTHLAND SPINE AND REHABILITATION, LLC
Entity type:Organization
Organization Name:NORTHLAND SPINE AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:OVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-569-5079
Mailing Address - Street 1:8002 N OAK TRFY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1268
Mailing Address - Country:US
Mailing Address - Phone:816-569-5079
Mailing Address - Fax:816-569-5298
Practice Address - Street 1:8002 N OAK TRFY
Practice Address - Street 2:SUITE 112
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-1268
Practice Address - Country:US
Practice Address - Phone:816-569-5079
Practice Address - Fax:816-569-5298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009013598111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty