Provider Demographics
NPI:1316153661
Name:SOUTHWEST SPINE AND SPORT, INC.
Entity type:Organization
Organization Name:SOUTHWEST SPINE AND SPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:Q
Authorized Official - Last Name:WARDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-772-8888
Mailing Address - Street 1:1722 DEL PRADO BLVD S STE 4
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-5522
Mailing Address - Country:US
Mailing Address - Phone:239-772-8888
Mailing Address - Fax:
Practice Address - Street 1:1722 DEL PRADO BLVD S STE 4
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5522
Practice Address - Country:US
Practice Address - Phone:239-772-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70007OtherBLUE CROSS BLUE SHIELD
FL70007Medicare ID - Type Unspecified