1710063060 NPI number — LAGS SPINE & SPORTSCARE MEDICAL CENTERS INC

Table of content: (NPI 1710063060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710063060 NPI number — LAGS SPINE & SPORTSCARE MEDICAL CENTERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGS SPINE & SPORTSCARE MEDICAL CENTERS INC
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:
LAGS SPINE AND SPORTS CARE MEDICAL CENTER INC
Provider Other Organization Name Type Code:
3
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:
1710063060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 CARMEN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93458-7729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-928-7361
Provider Business Mailing Address Fax Number:
805-928-5742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-736-7886
Provider Business Practice Location Address Fax Number:
805-736-7867
Provider Enumeration Date:
10/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAGATTUTA
Authorized Official First Name:
FRANCIS
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-736-7886

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ09772Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 106049802 . This is a "USDL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 726464 . This is a "AETNA PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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