1356885362 NPI number — VALLEY SPINE AND PAIN LLC

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 1356885362 NPI number — VALLEY SPINE AND PAIN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY SPINE AND PAIN LLC
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:
1356885362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35804-8545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-907-2493
Provider Business Mailing Address Fax Number:
256-281-8134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2227 DRAKE AVE SW STE 7B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-907-2493
Provider Business Practice Location Address Fax Number:
256-281-8134
Provider Enumeration Date:
12/09/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HORNBUCKLE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
256-907-2493

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  31801 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 186204 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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