1568979961 NPI number — SPINE AND WELLNESS INSTITUTE, PLLC

Table of content: (NPI 1568979961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568979961 NPI number — SPINE AND WELLNESS INSTITUTE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE AND WELLNESS INSTITUTE, PLLC
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:
1568979961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5550 WARREN PKWY STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75034-7399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-252-4777
Provider Business Mailing Address Fax Number:
469-518-2156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6300 W PARKER RD STE G25
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-8105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-252-4777
Provider Business Practice Location Address Fax Number:
469-518-2156
Provider Enumeration Date:
01/08/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KONING
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
951-317-4301

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  Q0953 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X , with the licence number: Q0953 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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