1164980744 NPI number — J&P SPINE CENTER INC.

Table of content: (NPI 1164980744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164980744 NPI number — J&P SPINE CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
J&P SPINE 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:
1164980744
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1593 E GREEN SAGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93730-8863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-433-9287
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6079 N FRESNO ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93710-5276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-433-9287
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OTCHERE
Authorized Official First Name:
JUSTICE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
682-433-9287

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: 1073957932 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".