1396054938 NPI number — CAMERON SPINE LLC

Table of content: (NPI 1396054938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396054938 NPI number — CAMERON SPINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMERON SPINE 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:
1396054938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6586 HYPOLUXO RD, STE 334
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE WORTH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-412-7272
Provider Business Mailing Address Fax Number:
561-967-0954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12989 SOUTHERN BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LOXAHATCHEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-412-7272
Provider Business Practice Location Address Fax Number:
561-967-0954
Provider Enumeration Date:
09/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CAMERON
Authorized Official First Name:
BLAINE
Authorized Official Middle Name:
SIMONE
Authorized Official Title or Position:
OWNER/PRINCIPAL
Authorized Official Telephone Number:
954-530-2643

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  ME86864 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 014293700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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