1235278565 NPI number — THE SPINE CENTER OF ROANOKE VALLEY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235278565 NPI number — THE SPINE CENTER OF ROANOKE VALLEY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE SPINE CENTER OF ROANOKE VALLEY, 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:
1235278565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4504 STARKEY RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-8540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-774-2513
Provider Business Mailing Address Fax Number:
540-774-0669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4504 STARKEY RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-8540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-774-2513
Provider Business Practice Location Address Fax Number:
540-774-0669
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STICKLE
Authorized Official First Name:
TRAVIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-774-2513

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0104555954 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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