1114473972 NPI number — BURBANK SPINE AND PAIN SURGERY CENTER A PROFESSIONAL MEDICAL CORP

Table of content: (NPI 1114473972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114473972 NPI number — BURBANK SPINE AND PAIN SURGERY CENTER A PROFESSIONAL MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURBANK SPINE AND PAIN SURGERY CENTER A PROFESSIONAL MEDICAL CORP
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:
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NPI Number Information

NPI Number:
1114473972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 W MAGNOLIA BLVD
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
BURBANK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91506-1753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-325-2088
Provider Business Mailing Address Fax Number:
818-563-6201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2211 W MAGNOLIA BLVD
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91506-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-325-2088
Provider Business Practice Location Address Fax Number:
818-563-6201
Provider Enumeration Date:
08/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AJAKWE
Authorized Official First Name:
REGINALD
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
818-325-2088

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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