1912185166 NPI number — LAGS SPINE AND SPORTSCARE MEDICAL CENTER, INC.

Table of content: (NPI 1912185166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912185166 NPI number — LAGS SPINE AND SPORTSCARE MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGS SPINE AND SPORTSCARE MEDICAL CENTER, 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:
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:
1912185166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2018
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:
354 S HALCYON RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ARROYO GRANDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-928-7361
Provider Business Practice Location Address Fax Number:
805-928-5742
Provider Enumeration Date:
02/08/2008

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:
805-928-7361

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  E057735 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E057735 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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