1477197671 NPI number — SPINE CENTER OF CT, PLLC

Table of content: (NPI 1477197671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477197671 NPI number — SPINE CENTER OF CT, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE CENTER OF CT, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477197671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11350 MCCORMICK RD
Provider Second Line Business Mailing Address:
EXECUTIVE PLAZA 1, SUITE 501
Provider Business Mailing Address City Name:
HUNT VALLEY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21031-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-329-1071
Provider Business Mailing Address Fax Number:
410-329-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 SAND PIT RD STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06810-4032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-743-7264
Provider Business Practice Location Address Fax Number:
203-792-3920
Provider Enumeration Date:
10/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
RAE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
571-223-8770

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com